A case of neurocysticercosis: Neuropsychiatric manifestations, course, and treatment.

Sir,

To the best of our knowledge, only few cases of patients with neurocysticercosis and mania have been reported,[12] all of them without any further description of the illness course and long-term treatment. In addition, the long-term course of cognitive function of these patients has not yet been investigated.[34] We report the case of a 69-year-old woman, in the chronic (calcified) stage of neurocysticercosis, followed up for 5 years, who presented with bipolar symptoms and treated with long-acting olanzapine. We focus on the course of neuropsychiatric symptoms as well as cognitive function.

A 64-year-old retired social worker was admitted who presented with severe agitation, aggression, irritation, and insomnia. She was disoriented and restless, with poor personal hygiene, had flight of ideas, pressured and loud speech. The patient's first psychiatric manifestations started at the age of 47 with manic- and depressive-like symptoms. At that point, she was diagnosed in the calcified stage of neurocysticercosis, and no serum or cerebrospinal fluid anticysticercal antibodies were found. Antiparasitic treatment with praziquantel followed by albendazol was given without any clinical change. Overall, she had four psychiatric admissions. After the onset of her mental disorder, the patient, who had previously been agreeable and sociable, retired from work, and her social functionality declined.

The current episode had started 1 month ago with overactivity, increased goal-directed activity, and elevated mood. Upon admission, her total Young Mania Rating Scale score was 18, and her Modified Mini–Mental State (3MS) examination score was 89. She was treated with haloperidol 2 mg/TID and valproic acid 600 mg/TID (46 μg/m plasma level). Within 1 week, her manic symptoms resolved, but after 1 week of normothymia, she gradually became sad, severely psychomotorly retarded, stuporous, opposed to taking her medication or food, and with poor speech (Hamilton Rating Scale for Depression score: 21). During her depressive episode, haloperidol was stopped and olanzapine per os 5 mg/OD was introduced, and she was discharged on normothymic after 18 days.

Computed tomography (CT) demonstrated multiple intraparenchymal calcifications compatible with neurocysticercosis in the granular stage [Figure 1a] and moderate dilatation of the lateral and third ventricles with a relatively normal fourth ventricle. The findings were confirmed with magnetic resonance imaging (MRI) [Figure 1b] which also demonstrated periventricular focal white matter hyperintensities compatible with chronic white matter ischemic changes. Single-photon emission CT showed normal tracer (99mTc-HMPAO) uptake and brain perfusion [Figure 2].

Figure 1

(a) Computed tomography: Multiple intraparenchymal calcifications secondary to cysticercosis in the granular stage. (b) Magnetic resonance imaging: T2-weighted image: moderate dilatation of the lateral and third ventricles with proportionate prominence of cortical sulci and periventricular focal white matter hyperintensities compatible with chronic white matter ischemic changes

Figure 2

Single-photon emission computed tomography with normal tracer (99mTc HMPAO) uptake and brain perfusion

Throughout the 5-year follow-up period, the patient presented cyclical periods of manic-like and depressive-like episodes lasting about 1 month each, with periods of ½ to 1 month of normothymia in between. She was administered long-acting injectable olanzapine 210 mg twice a month in monotherapy, and her symptoms were milder, with hypomanic symptoms restricted to overactivity and elevated mood without severe behavioral outbursts and aggression and depressive symptoms characterized by sadness and withdrawal, without negativism though.

In terms of cognitive functioning, her condition remained stable (3MS initial: 89, final: 84) without significant memory impairment for recent events, however, with a constant need of assistance for activities of daily living (Lawton Instrumental Activities of Daily Living Scale initial: 1, final: 1), and her Wechsler Adult Intelligence Scale test (IQ verbal 81, performance 67, difference marginally not significant) revealed weakness in the letter–number sequencing task. Her neurological examination did not demonstrate any significant abnormalities. Carotid and vertebral ultrasound gray-scale and Doppler spectral examination showed small nonstenotic plaques in the carotid bulb without changes in flow dynamics. Pulsed Doppler parameters (peak systolic and end-diastolic velocities) were normal. Finally, there was no interval change in the imaging findings on repeat MRI performed at the end of the follow-up period.

Manic episodes in patients with neurocysticercosis have been treated with risperidone and/or carbamazepine[1] or valproic acid[2] for patients with co-existing convulsions. We administrated long-acting injectable olanzapine with beneficial prophylactic effects, lowering the severity of manic and depressive symptoms to a set of milder ones without severe catatonic features such as excitement, stupor, or negativism. This effect was crucial in a patient with severe episodes, without illness insight and refusing to take psychotropic drugs per os.

Although it remains unclear to which extent the onset of a patient's bipolarity could be attributed to neurocysticercosis, we came to the diagnosis of bipolar disorder due to general medical condition/ neurocysticercosis (Diagnostic and Statistical Manual of Mental Disorders-5) because the infection preceded the manifestation of the affective symptoms and the presence of catatonic symptoms and severe executive dysfunction could be related to cysticercosis-induced cerebral changes rather than to a simply co-existing functional mental disorder per se. Besides, similar clinical pictures were described in patients with cysticercosis.[5] Cognitive functioning is usually assessed in the acute phase of neurocysticercosis. In contrast, there is lack of evidence regarding its long-term course in patients in calcified stage and old age. Our report underlines the need for close clinical and neuropsychological follow-up in neurocysticercosis and the usefulness of long-acting olanzapine in cases with bipolar features.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.