Case Studies

This 19 year old male patient presented with L. focal epilepsy for the first time. He had negative F/H of fits. No. H/O trauma or contact with kochs. Examination did not reveal any neurological deficit. Usually we use the criteria that if it is focal epilepsy or late onset epilepsy, with a negative F/H or a combination there of, we should investigate thoroughly to exclude a structural lesion, even if we find no neurological deficit on examination.

We first did the EEG which showed a slow wave focus but no evidence of neuronal hyperexcitability suggestive of a structural lesion. Hence a C.T. Scan was done. This revealed several hyperdense non enhancing lesions, suggestive of old granulomas, the largest one being in the R. parieto-occipital region.

Further investigations revealed a normal X-ray chest, Mantoux Test & ESR to make tuberculoma less likely. Stool examination did not show any taenia but soft tissue X-RAYS showed cigar shaped calcified deposits in the thighs suggestive of cysticercosis. So the cerebral lesions were also probably neurocysticercosis.

In the past, before the advent of modern neuroimaging, we used to often label these cases as focal epilepsy because, as the then available investigations including the invasive ones, could not pick up these small parenchymatous lesions. Furthermore we are now picking up evidence of cysticercosis even in pure vegetarian patients, not necessarily in pork eaters. Armed with the modern M.R.I. especially after administering gadolinium we are seeing quite a few cases of neuro-cysticercosis many of them having multiple lesions.

How do we treat these patients? With calcified granulomas we only have to treat with anti-epileptic medications. However if there are multiple active lesions or dying cysts we would advise a two week course of praziquantal at 50mg/kg in divided doses or albendazole at 800mg/day for 4 weeks. The precautions to be taken before giving these drugs are premedication with anti-epileptic medications in adequate doses and dehydrating measures as the I-C pressure can rise due to oedema as the cysts die and fits can break through.