Neurocysticercosis case presentation Dr Sudip Bhattacharya

Family Medicine Case

1. Presenter: Dr. Sudip Bhattacharya,
Junior Resident, Dept. of Community Medicine,
SPH,PGIMER, Chandigarh, India.
PGIMER, CHANDIGARH

2. Outline
What is NCC?
Case presentation
Psychological and social aspect of this case
Family diagnosis
Management
Individual level
Family level
Community level

3. Neurocysticercosis (NCC)
Neurocysticercosis (NCC) is the most common cause
of acquired epilepsy in developing countries
Caused by Taenia solium larva
Presents variably depending on the location and stage
of cysts in the nervous system, and the host immune
response
Parenchymal/ extraparenchymal/ others
Biological marker of the social and economic
development of a community- major public health
problem
Difficult to exactly estimate the disease burden of
NCC in a community study

4. Clinical features
Parenchymal (commonly in children)
Seizures (70-90%)
Headache and vomiting (33%)
Raised intracranial pressure with papilloedema (2.3–
6.6%)
Neurodeficit (4-6%)
Principles of Internal medicine,Harrisons-18th

5. Family profile
Name Age
(years )
Sex Education Occupation Income Health status
Hariram 37 M 5
th
stdWorks in
Godrej
factory
4,000 pmHealthy
Menadevi 35 F Illiterate Maid servant2,500 pmHealthy
Puja 13 F 8
th
stdStudent -- Cysticercosis
(NCC)
Sandhya 10 F 5
th
stdStudent -- Healthy
Prince 08 M 3
rd
stdStudent -- Healthy
Sonu 06 M 1
st
stdStudent -- Healthy
)lo-lowerlo
Address: sector 56,#3823, Chandigarh,

6. Chief complaints
A 13 year female child presented with
h/o nausea and vomiting for 5-6 days after taking
antiepileptic medication (on carbamzepine for last 4
years)

7. History of present illness
Before 5-6 days she was apparently well
 From 5-6 days nausea and vomiting started
It was insidious in onset and progressive in nature
Frequency was twice in a day and occurred when she
took her routine antiepileptic medication
It subsided by taking medication (ondansetron)
Before this episode another episode of vomiting
occured 1 month back

8. Cont .
Date Episo
de
Time Involvement Seen by What was done?
2008,
summer
1 Night GeneralizedGrand
mother
Slapping and sniffing of
shoes
16/7/ 20091 1 amGeneralizedMother Warming peripheries,
jaw retraction,
went to hospital
27/10/20121 8 pmGeneralizedMother Warming peripheries,
went to hospital
28/2/ 20131 8 amGeneralizedMother Warming peripheries,
went to PGI
16/9/20131 7 amGeneralizedMother Jaw retraction, PGI
Seizure events

9. Cont.
No H/o tongue bite, drolling of saliva
No H/o deviation of angle of mouth
There was no alteration of sleep pattern/behaviour
changes/school performances

10. Cont.
There is history of taking antiepileptic medication
(Carbamazepine for 4 yrs)
There is no history of:
Fever
Gastroenteritis
Indigestion
Blurring of vision
Headache
Menstrual problems

11. Antenatal history
It was not a booked case
No T.T. injection, IFA was taken
No such complications was present
No history of drug intake, radiation, high fever

12. Birth history
It was a home delivery by local aunty
Birth weight was not measured but according to
mother puja was healthy enough
Puja cried immediately after birth

13. Immunization history
Puja was given 1 st dose of vaccines(2 intramuscular
and 1 oral)—when father came from Chandigarh
After that no vaccine was given

14. Developmental history
Normal comparing to other children in the
neighbourhood

15. Family history
Uncle of Hari Ram was a
known case of PTB
(Chandigarh)
Was under PGI follow up
(HAEMOPTYSIS)
Died at PGI due to
complications of
TB 4 years back
(RESPIRATORY
PROBLEM)
Except Puja all
are healthy in
this family

16. Personal History & Dietary History
Non -vegetarian family , used to eat roasted pork in the
village
No habit of washing hand regularly before eating, after
toilet and play etc. Eats raw tomato and mulas without
washing.
Taking 2200/2180Kcal/d and protein 40/39.6g/d as per the
requirement.

17. Duration is about for 5
minutes, it was generalized
seizure
Hari ram shifted to his
family from Bihar to
Chandigarh for better
treatment
1 st episode of convulsion occurred at the
age of 5 yrs in the village of Bihar
(2008,april)
During
open air
defecation
subsided
with local
practices
(sniffing of
shoes,
slapping)
Grandmother
of Puja sought
care from faith
healers
/mother
sought care
from local
RMP doctor
As he worked
in Chandigarh
and knows
about PGI
Treatment History

18. 2
nd
episode (midnight) occured in Chandigarh
16/7/2009
(continued medicines of RMP doctors for 1 year)
They went to emergency of
Civil Hospital SAS nagar
After 5 days she was discharged with all
reports and advised for OPD check up
regularly
Treated
with Inj.
phenyto
in
Given Tab
Cabamaziepine and
Albendazole
CT scan
brain, EEG,
blood test
and chest X
ray done
(private/40
00Rs)

19. On 27/10/2012 again 3
rd

episode occurs
Again they went to Civil
hospital, SAS Nagar
They referred the case
to PGI emergency
It was
uncontrollabl
e
Again treated
with Inj.
Phenytoin

20. She was admitted in
PGI(28/10/12) for 3 days
Discharged with
advice (regular
check up in NCC
clinic)
28/2/13 another episodes
occurs and treated in PGI
emergency
EEG (N)and
CT scan,
done
(calcified
granuloma in
Right Parietal
region)
Tab Carbamazepine
16mg/kg body wt.
and Calcium 500mg
OD was given

21. 4/9/13 admitted in Paediatric emergency with
vomiting at 1 pm.
Treated with Inj. Emeset, Pantop and 5% RL,
Observed for 7 hrs and discharged with advice
Seizure occurs at 7 am, 16/9/13, observed in
emergency from 8 am to 2 pm and treated
with oral phenytoin and discharged
On 19/9/13 she came with
vomiting and treated in OPD
and advised for investigations
EEG and blood
carbamazepine
level

22. Environmental History-Bihar
Housing –kutcha, 2 rooms
Toilet –open air
Kitchen –out side, biomass fuel
Drinking water-from own tube well
Waste disposal outside the house
Problem of drinking water during summer and flood
occurs in rainy season

23. Environmental history-Chandigarh

24. Cont.

25. Socioeconomic status
Modified Kuppuswamy Classification
Lower middle class

26. Health seeking behaviour
Major as well as minor illness: Civil dispensary
Preferred civil hospital for emergency because it is
free and it is the nearest
For any emergency they used to come in PGI

27. Social
They are residing in Chandigarh for more than 5 years
They have no such problems faced till now
Good personal and social support from neighbours

28. Psychological
“Doctor saab, yeh daura kab
bandh hoga ?
Paisa ka problem ho raha
hai.
Mujhe is bimari ke karan
ghar se bahar nikalna para.
Puja ki pitaji ab bahut chir
chire rahate hai,aur gussa
mujh pe nikalte hai.”
Images are not real

29. Cont.
“Meri pyari beti pooja thik hogi
ki nahi? Rat ko daura ke bajah se
thik se nindh nahi ata hai.Har
mahine mei PGI jana kise pasand
hai? Ak to garib admi aur upar
se kaam bandh.Bhagban jane
uski padai ,saadi kaise hogi?
Kabhi kabar gussa ata hai fir
man ko samjhata hoon ki PGI
bale jarror thik karenge.”
Images are not real

30. Cont. “Mujhe kuch pata nahi
chalti hai .Mujhe jada
kuch problem nahi
hai,kebal bar bar school
bandh karna parta
hai.Mere pitaji jada pyar
mujhe karte hai.”
Images are not real

31. Economic burden
For last five years they spent Rs 20,000.
For regular check up and medication they spent Rs
1000/month.
It causes mental stress to that family.

32. Examination
General
Pulse -72/min, regular Pallor-absent
B.P.-120/74 mm of hg Cyanosis-absent
R.R.-18/min Jaundice-absent
Afebrile Clubbing- absent
H.C.-49 cm
Wt-36.4 kg
Ht.-117 cm
BMI-26.47

33. Systemic examination
G.I.T.- No signs of dehydration present
 Liver and spleen-NP
Resp.-B/l normal vesicular breath sounds present
C.V.S-S1,S2 normal
C.N.S-(H.M.F)-conscious oriented
 Motor-normal deep tendon reflexes
 B/l planter -flexor
 No neck rigidity
Ophthalmologic examination-normal (fundoscopy not
done)

34. Investigations
NCCT-Head(22/2/12): F/s/o calcified granuloma in
right parietal lobe. Compared to previous CT done
16/7/2009,there is no significant interval change.
Chest X Ray=normal
EEG-normal awake EEG report

35. CT scan

36. CT scan-(Calcified granuloma)

37. EEG(Normal-spikes)

38. Differential Diagnosis
Differential Diagnosis
Neuro-
cysticercosis
Tuberculoma
GTCS
Intake of roasted pork
Poor hand hygiene
Unwashed vegetables
Contact with PTB
(Dada)
No symptoms of
TB

39. Steps
Direct Indirect
Microscopy
Radiology Serology
Copro-antigen
detection
Molecular
CT MRI
Ab Ag
PCR
Serum,
CSF,
Urine,
Saliva
Serum,
CSF,
Urine,
Saliva
 Diagnosis

40. Diagnostic Criteria
Absolute EpidemiologyMinorMajor
1. Histological
demonstration
2. Cystic lesions
with scolex on
NI, or
3. Direct
visualisation of
ocular cysts
1. Suggestive
lesions on NI.
2. +ve sr.
immunoblot

3. Resolution of
cysts after
therapy
4.
Spontaneous
resolution ELs
1.Compatible
lesions on NI

2. Compatible
clinical
manifestations

3.. +ve CSF ELISA
4. Cysticercosis
outside CNS
1. Household
contact
2. Living in an
endemic area

3. Travel to
endemic areas.
Degrees of certainty
Definitive diagnosis : 1 Absolute or 2 Major +1 Minor+ 1 Epi.
Probable diagnosis : 1 Major+ 2 Minor or 1 Major + 1Minor+1 Epi or 3
Minor + 1 Epi.
.
Principles of Internal medicine,Harrisons-18th

41. Family diagnosis
 A 13 year old girl belonging to lower middle class,
(modified Kuppuswami scale) nuclear hindu (harijan)
family suffering from Neurocysticercosis on
antiepileptic (carbamazine) medication and having
suspected drug over dose with no neurological deficit
at present.
Other members of this family are apparently healthy
but parents are having some mental as well
economical stress.

42. Management
Individual level-
Tab Carbapazepine 16mg/kg/body weight
Tab Ondansetran 4mg stat and sos
To attend OPD after doing investigations
To attend paediatric ER sos
Danger signs explained
To maintain hygeine

43. Cont.
Family level-
General hygiene (Hand) and washing of fruits and
vegetables.
Clean and safe water.
Proper cooking of meat.
Cysticidal therapy to all family members.
First aid if seizure recurs and reporting to hospital.

44. Cont.
Community level-

Education and general awareness about the zoonosis
Prevent roaming of the pigs to excrements
 Use latrines and general hygiene measures (washing
hands)
Proper cooking of pork before consumption
Education and general awareness to the pig keepers
 Municipalities should maintain strict measures
related to meat control and control use of wash
water

45. Cognition- Identity & Cause

46. Cognition on Pork tape worm and NCC
How seizures?
Route of entry
Where does it enter
first and reside?
Consequences
How to prevent?
Curability
Timeline

47. 1.Daura ke time kya karti
ho?
2.Ye thik ho sakta hai?
3.Dabai kitna din dena
parega?
1.Hath per garam karti
hoon,jabra ko daba ke
rakhti hoon.
2.Haan.
3.Doctor saab ne teen sal
bataia tha lekin abhi bhi
dabai chal raha hai.

48. Life Cycle- Cestode: Taenia solium
(ICD 10-B68,71(NCC-B69))
NATURAL HISTORY
OF DISEASE IN
THIS CASE
Intake of roasted
pork in village
No regular hand
washing habit
Unwashed raw
vegetables
Auto infection-
exogenous or
endogenous

49. Discussion
Problem of caregiver
Hari rams future intention

51. PGI
Bihar
BIHAR
CHANDIGARH

52. THANKS
PGIMER