Disseminated neurocysticercosis presenting as affective mood disorder with chronic tension type headache
A 21-year-old woman residing in New Delhi presented to the Department of Medicine with a history of insidious onset, progressive headache on and off for the past 6 months. The headache was bilateral, dull aching in nature occurring at any time of the day and had no special character or precipitating factors. It was not associated with vomiting. It was associated with fatigue, low mood, irritability and loss of appetite, multiple somatic pains and crying spells. Initially, the headache was relieved by over the counter analgesics, but it used to recur after a few days. After 2 months of persistent symptoms, she had consulted a physician where she had been diagnosed to have tension type headache. A formal psychiatric evaluation done at that time revealed minor depressive episode. When her symptoms did not abate she was started on amitriptyline 25 mg once daily for prophylaxis of chronic tension type headache. When she presented to our hospital her headache had worsened in severity and frequency. There was no history of blurring of vision, diplopia, squint, pain, redness or watering of eyes. There was no history suggestive of any other cranial nerve palsy. There was no history of vomiting or seizures. There were no medical comorbidities. Her elder sister had a history of seizure disorder for which she had been taking anti-epileptic drugs for the past 2 years. The general examination was unremarkable. There were no subcutaneous swellings. Visual acuity was 6/6 in both eyes. Visual fields were normal. Cranial nerve examination was normal. There were no signs of meningeal irritation. Rest of the CNS examination was normal and fundoscopy was normal. Rest of the systemic examination was normal. Raised intracranial tension (ICT) leading to secondary headache was suspected. A non-contrast computed tomography of the head showed multiple hypodense lesions. A contrast enhanced magnetic resonance imaging was done, which showed multiple cystic lesions with eccentric nodules in bilateral basal ganglia, cerebellum, brainstem, cerebral hemispheres; a few of them indenting the lateral ventricle. Many ring enhancing lesions were also visualized throughout the brain parenchyma. Similar lesions were seen in the scalp, posterior pharyngeal wall, masseter, pterygoids, paravertebral neck muscles and tongue []. There was a single lesion in left orbit abutting the superior rectus and a single lesion in the right orbit abutting the optic nerve [Figures and ]. X-ray of the thigh showed multiple cigar shaped calcifications []. Her complete blood count, liver function test, kidney function test were within the normal limits. Based on the imaging findings a definite diagnosis of neurocysticercosis with extra-cranial dissemination was made. Amitriptyline was stopped. She was started on albendazole with oral steroids and neuroimaging follow-up was planned. After 2 months follow-up, her headache had decreased and she did not complain of any myalgia. There was remission of her affective mood disorder as documented by a psychiatry consultation.