Pearls & Oy-sters: A rare case of neurotrichinosis with MRI

Abstract

Pearls & Oy-sters: A rare case of neurotrichinosis with MRI PEARLS 1. The neurologic manifestations of trichinosis are diverse and range from encephalopathy to cerebral, cerebellar, and spinal cord abnormalities. 2. MRI lesions enhance with contrast and are postulated to represent small areas of infarction. 3. Imaging typically normalizes within 1 to 2 months after infection. OY-STERS1. Neurotrichinosis should be considered in patients with marked eosinophilia and unexplained neurologic symptoms. 2. Outcomes may be improved with the administration of steroids and anthelmintic agents during the enteral phase of infection.CASE REPORT A 41-year-old left-handed man from a northern Canadian district presented to a community hospital with a 3-week history of watery diarrhea, a self-resolved erythematous pruritic rash, fever, confusion, and facial swelling. A CT scan of the head showed areas of decreased attenuation bilaterally in the periventricular regions of the frontal lobes. He was offered admission for workup but declined and was sent home with antibiotics. He returned to the hospital 3 days later with new complaints of left face numbness as well as left arm numbness, weakness, and clumsiness. His partner noted that he was sleeping more than usual and had word-finding difficulties. Other symptoms included daily bifrontal headache, "red spots" briefly appearing in his visual field, and ataxia. Medical history was significant for vasectomy, 20-pack-year smoking history, and headaches. He had no allergies and no regular medications.On admission, vital signs were within normal limits, and there was no documented fever. Cardiorespiratory and abdominal examination results were normal. There was no facial edema or skin lesions. Cognition was intact. He had a normal cranial nerve and sensory examination. Strength in the left upper extremity was decreased to 4/5 in all muscle groups. The remainder of the strength examination was normal. Reflexes were present and symmetric. There was a left-sided pronator drift, slowing of finger-to-nose testing, and inability to perform rapid alternating movements with the left arm. Gait was unstable, and the patient used a wheelchair to mobilize in the hospital.Laboratory tests were remarkable for a leukocyte count of 15.3 3 10 9 /L, an eosinophil count of 5.8 3 10 9 /L (38%), platelets of 147 3 10 9 /L, creatine kinase of 290 U/L, troponin of 3.12 mg/L, and erythrocyte sedimentation rate of 34 mm/h. There was no evidence of ST elevation on ECG, and chest x-ray was normal. CSF analysis showed glucose of 57.6 mg/dL, protein 34 mg/dL, erythrocytes 9.5/mm 3 , leukocytes 3.6/mm 3 , and a negative Gram stain and culture. There were too few leukocytes in the CSF to provide a differential. Blood cultures, stool culture, and stool for ova and parasites were all negative. Rheumatologic markers were negative. Echocardiogram showed normal ventricular and valvular function. An EEG showed slow-wave activity in the left temporal region. There was no epileptiform activity.Brain MRI (figure) demonstrate...

Central Nervous System Involvement in Trichinellosis: A Systematic Review

“…Psychiatric and behavioral disturbances are not very frequent. Cognitive impairments consist mainly of deficits in recent memory [20,46,61,62,76,79,103], resembling Korsakoff syndrome and aphasia [20,34,41,70,76,94,99,101,105].…”

“…In T1 sequences, patients presented a slight signal increase [97] or hypointense lesions [101]. The DWI sequences revealed a restricted diffusion, suggesting ischemia [97,101]. In apparent diffusion coefficient (ADC) sequences, the lesions were hypointense [98].…”

“…Most authors reported the presence of high signal lesions in the T2 weighted sequences, located in the white matter [20,87,94,97,98,101,102,105,106]. In T1 sequences, patients presented a slight signal increase [97] or hypointense lesions [101]. The DWI sequences revealed a restricted diffusion, suggesting ischemia [97,101].…”

“…Interestingly, some papers reported that the lesions were situated in the border zones of distal fields of major cerebral arteries [97,98,105,106]. Although most of the lesions were reported to be in the white brain matter, the MRI scans also detected lesions at the white matter and grey matter interface, in the cortex [102], cerebellum [98,101,105,106], and thalamus [106]. Furthermore, McDonald et al [101] observed that the lesions were distributed mainly in the frontal and parietal lobes, with fewer lesions in the temporal and occipital lobes and cerebellum.…”

“…Some of the lesions found on MRI presented rim enhancement [101], or peripheral enhancement, indicating a breakdown of the blood-brain barrier [98], focal nodular enhancement [94], or focal gyriform enhancement [94].…”