Reversible dementia as a presenting manifestation of racemose neurocysticercosis
A 62-year-old lady presented with headache, slowness in activities of daily living and progressive memory disturbances of 8 months duration. For the last 6 months, she also had gait disturbance with slowness in activities of daily living and urinary incontinence. Her general examination was normal. Systemic examination was unremarkable. She had impairment of higher mental functions with Mini Mental Score Examination (MMSE) of 10/30. Cognitive domains severely affected were executive function, recent memory, visuospatial skills and calculation. Cranial nerves were normal and fundus examination did not show any papilledema. Motor examination revealed increased tone in all four limbs with cogwheel rigidity. Power was normal and deep tendon reflexes were brisk. Plantar reflex was flexor bilaterally. Sensory examination was normal. She had short shuffling gait. The hemogram was normal and biochemical parameters were within normal limits. She underwent magnetic resonance imaging (MRI) of the brain, which showed multiple variable-sized solitary and conglomerate cystic lesions in the right sylvian fissure, basal cisterns, sulcal spaces and third ventricle, which were hypointense on T1-weighted and fluid-attenuated inversion recovery (FLAIR) sequences and hyperintense on T2-weighted sequences []. No scolex was seen within the cysts. The anterior part of right lateral ventricle was pushed medially by conglomerate cystic lesions in the right sylvian fissure, but there was no midline shift. There was obstructive hydrocephalus with dilatation of lateral ventricles and third ventricle. Fourth ventricle was not dilated and cause of hydrocephalus was cyst in the third ventricle. Contrast-enhanced images showed patchy enhancement of cyst walls and septae []. There was no perilesional edema or any evidence of arachnoiditis. Diagnosis of racemose NCC was kept. She was given high-dose steroids and underwent ventriculoperitoneal shunting. NCC serology (ELISA for IgG antibodies) in serum and cerebrospinal fluid (CSF) was positive with titers of 1:1600 and 1:80, respectively. Post shunting, she had significant improvement in her cognitive status, with MMSE improving to 22/30 at the time of discharge 6 days post shunting. Her gait also improved and she became continent. She was discharged on oral steroids. Cysticidal therapy was withheld due to concerns regarding provoking acute brain inflammation and ependymitis from the death of cysts.