Neurocysticercosis-AP.pptx

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1. Case Presentation Presented by : Arief Pratama C155202001       Supervisor : Dr. dr. Andi Kurnia Bintang, Sp.S (K), MARS

2. HISTORY TAKING Mr. T. L. A 51 year-old man was admitted to emergency room with complaint loss of consciousness which was happened gradually since 7 days ago. Patient seemed agitated , could not communicate well, lack of response . At first, patient complained he had headache since 2 weeks ago , which more severe around 1 weeks ago; alongside with fever, and focal seizure. There were history of last occupation as a fish farmer. There weren’t clear history about using recreational drugs, alcoholic, blood transfussion . 2

3. Physical examination Head : normocephalic Eye : anemia conjunctival -/-, scleral icterus -/- Mouth : normal Thorax : Heart sound I-II regular, no murmur Respiratory sound ves / brchves , rhonchi -/+, wheezing -/- Abdomen : peristaltic is present, WNL Extremity : oedema not presented Vital sign BP 165/85 mmHg HR 98/minute RR 24/minute T 39.2 C 3

4. Neurological examination Glasgow coma scale : E3M5V2 Higher cortical function : Can not be evaluated Meningeal sign : Nuchal rigidity positive Kernig sign +/+ Cranial nerve : Round pupil, isochoric, ⦶ 2mm/2mm bilateral DLR +/+, ILR +/+ Other cranial nerves : Can not be evaluated 4

5. Neurological examination Motoric function : Movement and strength without lateralization Tonus Physiological reflex BPR +2 +2 TPR +2 +2 KPR +2 +2 APR +2 +2 Pathological reflex Hoffman- tromner - - Babinski - - Sensory function : Can not be evaluated Autonomic function : Urinate : normal Defecate : normal 5 N N N N

6. Clinical diagnosis : Loss of consciousness + Focal Seizure + Fever of unknown Origin Topical diagnosis : Meningens + bihemisphere + Cortical Etiological diagnosis : Infection / Inflamation Working diagnosis 6

7. Laboratory tests 7

8. Early treatment Citicoline 500 mg q12hr IV Mecobalamin 500 mcg q24hr IV Ceftriaxone 2 gr q12hr IV Paracetamol 500 mg q8hr PO Ranitidin 50mg q12hr IV Dexamethasone 5mg q6hr IV ( Tappering Off/ Day) Levetiracetam 500mg q12hr oral Electrolyte Correction ( Hiponatremia (120 mEq /L )) with NaCl 3% q24hr 10 drips per minute   Plan: Folley catheter and nasogastric tube Non Contrast Head CT-scan Chest X-Ray Complete laboratorium tests HIV Screening test Consult to Pulmonologist 8

9. Interpretation: Sinus tachycardia, left axis deviation, normal P wave, normal QRS complex . ECG 9

10. MSCT Head 10

11. Multiple cystic lesions (HU 25): firm boundaries, irregular edge at bilateral frontal region with central dot sign and perifocal oedema Hipodens lesion (18 HU) in frontal bilateral region and falx cerebri that filling sulcus and gyrus at right parietal region.   Interpretation : Multiple hipodens lesion at frontal bilateral region, temporal sinistra, bilateral subdural frontal and subarachnoid parietal dextra suspect neurocysticercosis Brain oedema MSCT Head 11

12. Chest X-Ray 12 Pneumonia Dextra Slight Cardiomegaly Suspect plate like athelectasis right lung

13. Follow up 13

14. Follow up 14

15. Clinical diagnosis : Loss of consciousness + Focal Seizure Topical diagnosis : Bilateral frontal, temporal sinistra, bilateral frontal subdural, subarachnoid parietal dextra Etiological diagnosis : Neurocysticercosis (Probable) Final diagnosis 15

16. NeurocystIcErcosis Parasitic disease cause by t. solium , which is endemic in south America, asia , and Africa Weeks to years following ingestion, tissue cysticerci develop in various sites, including the brain Symptoms depend on location – seizures ( Intraparencymal ) Diagnosis – Imaging most common, but Serology, Fundoscopic exam, Spinal studies and biopsy may also aid Treatment – antiparastics , anti-inflammatories, surgery

17. Clinical manifestation Intraparenchymal ncc Seizure Cognitive impairment Neurological deficit (hemiparesis) Extraparenchymal ncc Subarachnoid (intracranial ht , arachnoiditis/ meningitis) Intraventricular (hydrocephalus) Spinal Orbital or ocular (visual deficit, eye movement limitation) Case Presented with Agitated Loss of conciusness (somnolence) Fever Focal seizure file:///C:/Users/ASUS/OneDrive/Desktop/case%20infeksi/NCC,%20pratibha%20singh.pdf

18. Imaging findings Imaging findings vary based on stage of infection Vesicular – cystic, hypodense, round Colloid vesicular – cyst begins to degenerate: cyst wall and cavity increases In intensity, surrounding enhancement 2/2 edema (best visualized by flair on mri ) Granular Nodular – Cyst retracts, edema decreases, decreased enhancement Nodular calcified – calcified granuloma, no enhancement Only pathognomonic findings = scolex Elongated, bright nodule within cyst cavity (Fig. B)

19. case Multiple cystic lesions (HU 25): firm boundaries, irregular edge at bilateral frontal region with central dot sign and perifocal oedema Multiple hipodens lesion at frontal bilateral region, temporal sinistra, bilateral subdural frontal and subarachnoid parietal dextra suspect neurocysticercosis Patognomonic sign (+) scolex Vesicular stage (hole in dot sign appearance)

20. Diagnostic criteria

21. management Our patient? Albendazole 15mg/ kgbw (70kg) = 1000mg/24hr/oral (administer for 30 days) Dexametason 5mg/iv/for 10 days Levetiracetam 500mg/12hr/oral

22. Questions?