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Mood and Psychotic Symptoms With Neurocysticercosis

Key Words: Modafinil • Depression

TO THE EDITOR: We recently treated a case of neurocysticercosis in a patient exhibiting mood and psychotic symptoms. The patient's depression paralleled her history of hydrocephalus. New psychotic symptoms followed recent progression of CNS lesions that led to a diagnosis of neurocysticercosis and anti-parasitic treatment. Her psychotic symptoms responded to risperidone.

Case Report

A middle-aged woman with a 20-year history of hydrocephalus was admitted after a recent change in behavior in which she reported confusion, poor concentration, headache, and nausea. She had had a ventriculo-peritoneal shunt in 1981. Right temporal cyst aspiration, ventriculostomy, and stereotactic biopsy of right temporal lesions had been done 3 months earlier. She had a long history of depressed mood with neurovegetative symptoms. She had recently been prescribed extended-release venlafaxine, with which she had been noncompliant. Her medication regimen included extended-release venlafaxine, 150 mg every morning; zolpidem, 10 mg h.s.; and ranitidine. An MRI scan revealed a right temporal cystic mass with stable enhancing nodule with increase in right-to-left midline shift. Drainage of the right temporal lobe cyst and trapped ventricle was performed. After consultation with the infectious disease service, a diagnosis of neurocysticercosis was given, and treatment with rifampin, vancomycin, and albendazole was prescribed.

Psychiatric consultation was obtained to assess hallucinations that had been reported following the neurosurgical procedure. The patient described an episode of having seen her "dead dog" (the dog was actually alive). She had reported hearing the voices of her children. She had also gotten out of her bed "to go to work" and exhibited other confused behaviors.

During a mental status examination she exhibited anxious and tearful affect. Her thought processes were mildly circumstantial. She had no suicidal or homicidal ideations and no hallucinations or delusions during the interview. Her Mini-Mental State Examination (MMSE) score was 26. An oral regimen of risperidone, 0.5 mg b.i.d., was added. Twelve days after admission, she reported that she was feeling less depressed, her neurovegetative symptoms had improved, and she was experiencing neither delusions nor hallucinations. Her MMSE score improved to 30.

Discussion

Neurocysticercosis is caused by neuronal infection by the larval form of the pork tapeworm Taenia solium. Its prevalence approaches 4% in rural areas of the developing world.¹ Neurological symptoms commonly include seizures and hydrocephalus. Psychiatric symptoms have been frequently reported; severity of psychiatric symptoms may correlate with treatment of neurocysticercosis with anti-parasitic drugs, associated with an increase in CNS inflammation.¹ Forlenza et al. reviewed 38 cases of neurocysticercosis.¹ Psychiatric illness and cognitive decline were seen in 65.8% and 87.5% of cases, respectively. Depressive disorders (in 52.6%) were the most frequent noncognitive psychiatric illness; psychosis was seen in 14.2%. Progression of disease and intracranial hypertension correlated with higher levels of psychiatric comorbidity. Previous episodes of depression correlated with recurrence of depression in active disease.

Sotelo et al.² reviewed 753 cases and reported intellectual deterioration in 15.8%, psychosis in 4.7%, and behavioral disturbance in 2.7%. These symptoms were more common with hydrocephalus or multiple lesions. In a review of 23 cases, Loo and Braude³ found that in 56%, the presenting symptom was psychiatric, while abnormal mental status examination results were a presenting sign in 43%.

McCormick et al.⁴ reviewed 127 cases and found that 38% had intracranial hypertension; 10% had increased intracranial pressure and dementia. In a review of 17 cases, Grisolia and Wiederholt⁵ reported that 18% exhibited altered mental status because of increased intracranial pressure. Scharf⁶ reviewed 238 cases; at some point during the course of illness, 33% experienced altered mental status. Two percent presented with dementia, 3% with psychosis. Wadia et al.⁷ reported three cases of disseminated cysticercosis (involving brain and muscle tissue); all exhibited dementia, and two cases experienced psychosis.

Our patient had had hydrocephalus for 20 years. It is plausible that her chronic depression was related to previously undiagnosed neurocysticercosis. Following progression of symptoms, a diagnosis of neurocysticercosis was made and anti-parasitic therapy started. Shortly thereafter, she experienced the onset of psychotic symptoms, which responded to risperidone. The presentation of psychotic symptoms may have been a result of neurocysticercosis progression or the onset of anti-parasitic treatment.

It is possible that her symptoms represented major depression with psychotic features. Nonetheless, her onset of psychotic symptoms and their temporal relationship to progression of her neurocysticercosis is compelling, and the available literature describes a significant comorbidity of psychiatric symptoms in neurocysticercosis. Physicians managing such patients are advised to be alert for comorbid psychiatric symptoms and be willing to offer specific psychopharmacologic treatment.

REFERENCES

1. Forlenza OV, Filho AH, Nobrega JP, dos Ramos Machado L, de Barros NG, de Camargo CH, da Silva MF: Psychiatric manifestations of neurocysticercosis: a study of 38 patients from a neurology clinic in Brazil. J Neurol Neurosurg Psychiatry 1997; 62:612-616[Abstract]
2. Sotelo J, Geurrero V, Rubio F: Neurocysticercosis: a new classification based on active and inactive forms. Arch Intern Med 1985; 145:442-445[Abstract]
3. Loo L, Braude A: Cerebral cysticercosis in San Diego: a review of 23 cases and a review of the literature. Medicine 1982; 61:341-359[Medline]
4. McCormick GF, Zee C-S, Heiden J: Cysticercosis cerebri: review of 127 cases. Arch Neurol 1982; 39:534-539[Abstract]
5. Grisolia JS, Wiederholt WC: CNS cysticercosis. Arch Neurol 1982; 39:540-544[Abstract]
6. Scharf D: Neurocysticercosis: two hundred thirty-eight cases from a California hospital. Arch Neurol 1988; 45:777-780[Abstract]
7. Wadia N, Desai S, Bhatt M: Disseminated cysticercosis: new observations, including CT scan findings and experience with treatment by praziquantel. Brain 1988; 111(Pt 3):597-614

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Bourgeois, J. A. Articles by Mehra, N. Search for Related Content PubMed Citation Articles by Bourgeois, J. A. Articles by Mehra, N. Other Childhood Disorders Syndromes Secondary to General Medical Disorders

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