Reversible parkinsonism associated with neurocysticercosis

Abstract

A 38-year-old female was assessed in a county hospital with a four-month history of severe throbbing morning headaches. Due to the syndromic diagnosis of intracranial hypertension, a brain magnetic resonance imaging (MRI) was performed showing evidence of supratentorial noncommunicating hydrocephalus because of an intraventricular cyst. The cyst was located at the level of the frontal horn of the right lateral ventricle, extending through the foramen of Monro to the third ventricle. Additionally, there were signs of edema in the midbrain periaqueductal region. The patient was treated with a ventriculoperitoneal (VP) shunt, and the symptoms of intracranial hypertension improved. A diagnosis of neurocysticercosis (NCC) was established after analysis of CSF, and positive antibodies reactions were detected. The patient was started on high-dose oral albendazole (3.2 g qd). After four days, additional signs were detected, including mutism, hypomimia, and sialorrhea, associated with severe parkinsonism (marked rigidity, bradykinesia, and resting upper limb tremor). A new brain MRI showed milder hydrocephalus. However, the intraventricular cyst and cerebral aqueduct edema and ependymitis remained unchanged (Figs 1 and 2).At such point, she was referred to our Service of Neurology at the Hospital de Clínicas, Federal University of Paraná. On admission, neurological examination showed a severe Parkinsonian syndrome that also included marked postural instability, anarthria, and vertical ophthalmoparesis for upward gaze.Our diagnosis was of Parkinsonism secondary to NCC. We believe that treatment with high-dose albendazole made the presentation worse by adding a reactive inflammatory response and by aggravating ependymitis and tissue damage.Methylprednisolone pulse therapy was then started (1 g intravenous, daily, for five days). Symptomatic treatment also included levodopa/carbidopa (250/50 mg daily), with progressive improvement in Parkinsonism symptom. Finally, she then underwent endoscopic neurosurgery including monroplasty, removal of the cyst, pellucidoctomy, and third ventriculostomy. Neuropathological examination confirmed the diagnosis of NCC.Eight months later, the patient was progressively withdrawn from dopaminergic treatment and remained asymptomatic, able to return to her routine activities.

Movement Disorders in Systemic Diseases

“…Although neurocysticercosis is the most common cause for seizures in developing countries and the parasitic cysts affect the basal ganglia in 25%, movement disorders occur in only 3.5% of cases. 7,28 A few case reports have described levodopa-responsive akinetic-rigid parkinsonism 29,30 ; however, in most cases, parkinsonism is secondary to hydrocephalus. 7 Further, dystonia, hemichorea, myoclonus, and hemifacial spasms have been described.…”