Delayed diagnosis of spinal cord schistosomiasis in a non-endemic country: A tertiary referral centre experience.

BACKGROUND: Neuroschistosomiasis is a severe complication of schistosomiasis, triggered by the local immune reaction to egg deposition, with spinal cord involvement the most well recognised form. Early treatment with praziquantel and high dose steroids leads to a reduction of neurological sequelae. The rarity of this condition in returning travellers to high income countries can result in delayed diagnosis and treatment. We aimed to evaluate the diagnosis and management of neuroschistosomiasis in a UK national referral centre. MATERIALS/METHODS: A retrospective review of confirmed clinical cases of spinal schistosomiasis referred to the Hospital for Tropical Diseases, UK, between January 2016 and January 2020 was undertaken. Electronic referral records were interrogated and patient demographic, clinical, laboratory, and radiological data collected. RESULTS: Four cases of neuroschistosomiasis were identified. The median age at diagnosis was 28 (range 21 to 50) with three male patients. All patients had epidemiological risk factors for schistosomiasis based on travel history and freshwater exposure; two in Uganda (River Nile), one in Malawi and one in Nigeria. All patients presented with features of transverse myelitis including back pain, leg weakness, paraesthesia and urinary dysfunction. The mean time from presentation to health services to definitive treatment was 42.5 days (range 16-74 days). Diagnosis was confirmed with CSF serology for schistosomiasis in all cases. Radiological features on MRI spine included enhancement focused predominantly in the lower thoracic spinal cord in three cases and the conus in one patient. All patients received a minimum of three days of oral praziquantel and high dose steroids. At three-month follow-up, one patient had complete resolution of symptoms and three had residual deficit; one patient was left with urinary and faecal incontinence, another had urinary retention, and the final patient has persistent leg pains and constipation. CONCLUSION: We observed a marked delay in diagnosis of neuroschistosomiasis in a non-endemic country. We advocate undertaking a thorough travel history, early use of imaging and CSF schistosomal serology to ensure early diagnosis of neuroschistosomiasis in patients presenting with consistent symptoms. If schistosomal diagnostics are not immediately available, presumptive treatment under the guidance of a tropical medicine specialist should be considered to minimize the risk of residual disability. We advocate for consensus guidelines to be produced and reporting to be performed in a uniform way for patients with spinal schistosomiasis.

Nematode eggs observed in cytology of cerebrospinal fluid diagnostic for intramedullary Spirocerca lupi spinal cord migration.

Spinal spirocercosis due to aberrant Spirocerca lupi nematode migration is an emerging etiology for acute myelitis in dogs in Israel, causing severe, mostly nonsymmetrical hind limb paresis or paralysis, and sometimes tetraparesis or tetraparalysis. So far, incidental identification of parasites during spinal surgery or at necropsy provides the only definite diagnosis, while antemortem diagnosis of this condition has been uncertain. Specifically, antemortem diagnosis is based on the typical clinical presentation of acute, progressive, asymmetrical hind limb paresis or paralysis, with moderate to severe eosinophilic to mixed cerebrospinal fluid (CSF) pleocytosis and increased CSF protein concentration. Exclusion of other differential diagnoses also requires using spinal cord imaging. In this novel report, we document a case of an intradural spinal spirocercosis in a dog, diagnosed antemortem, by detecting S lupi eggs in the CSF, and subsequent treatment, resulting in the resolution of the clinical signs.

[Application of CT and MRI in the Diagnosis of Paragonimiasis in Brain and Spinal Cord].

Clinical data of 22 cases with paragonimiasis in brain and spinal cord in the Central Hospital of Enshi Tujia and Miao Autonomous Prefecture during 2003 -2012 were retrospectively analyzed. Twenty-two cases aged from 6 to 17 years old, including 15 males and 7 females, were from the countryside, and had a history of eating raw crabs. CT and MRI showed that all the cases had cerebral lesion, 16 cases had unilateral lesion of cerebral hemisphere, and 6 cases had bilateral hemisphere lesions. There were mainly two kinds of imaging changes: (1) the infarct and low- density edema of large area with focal hemorrhage; (2) annular lesions. Among the 6 cases with intracerebral hematoma, 2 patients received surgical removal, and all the patients were treated with praziquantel, 25 mg/kg each time, 3 times per day, 3 d for a course. This regimen was repeated at a 7-day interval. All the patients were cured and discharged from hospital.

Intramedullary spinal cord neurocysticercosis presenting as Brown-Séquard syndrome.

BACKGROUND: Cysticercosis is a parasitic disease caused by the larval stage of Taenia Solium. Involvement of the central nervous system by this tapeworm is endemic in developing countries. However, isolated spinal involvement by Taenia Solium is uncommon and having clinical presentation of Brown-Séquard syndrome is even rarer. CASE PRESENTATION: A 43-year-old male who came to the emergency department with clinical presentation of complete Brown-Séquard syndrome. Computed tomography scan of the brain was normal. Magnetic resonance imaging of the thoracic spine revealed an intramedullary mass of the spinal cord at C-7/T-l level. Patient underwent surgery that revealed a cystic lesion and was resected. Histopathological report confirmed the diagnosis of neurocysticercosis. Postoperatively, oral steroid therapy and a four week course of albendazol were administered. CONCLUSIONS: Intramedullary neurcysticercosis represents a diagnostic challenge and should be considered in intramedullary lesions in settings where Taenia solium is endemic. Clinical, pathophysiological and diagnostic aspects of spinal cord intramedullary neurocysticercosis are discussed.

Cerebral and non-cerebral coenurosis in small ruminants.

Cerebral coenurosis is caused by Coenurus cerebralis, the larval stage of Taenia multiceps. The metacestode causes severe lesions in the brain and spinal cord of the intermediate host, so-called "gid" or "stagger" disease. Whereas, the non-cerebral coenurosis caused by Coenurus gaigeri, the larval stage of Taenia gaigeri, particularly affects goats. The cyst form of the Taenia gaigeri is found in intramuscular and subcutaneous tissues. The difference in the sequence of mitochondrial genes of cox1 and nadI and also other variations reported for clinical, morphological and pathological aspects in coenurosis lead to the hypothesis that there is genetic intraspecific variability within this species, such as in other members of the genus Taenia. Nevertheless, it has been shown that sheep and goats have been infected by both cerebral and non-cerebral coenurosis and it has been suggested that such cerebral and non-cerebral metacestodes may belong to different species of Taenia which are host specific for these hosts.

Acute paraplegia caused by Schistosoma mansoni.

Schistosomiasis affects over 200 million people worldwide. Involvement of the CNS is a rare occurrence. We report 2 young males who presented with rapidly progressing paraparesis associated with urinary incontinence. In both cases, MRI of the spine demonstrated a diffusely enhancing mass at the conus medullaris with extensive spinal cord edema. Laboratory investigations revealed mild peripheral eosinophilia and abnormal, but non-specific, CSF analysis. In one patient, the diagnosis was made based on a rising schistosomal titer with a positive rectal biopsy. In the other patient, spinal cord biopsy revealed a granuloma. Both cases were caused by Schistosoma mansoni and patients were treated with praziquantel and steroid therapy. They both made a remarkable neurological recovery. We emphasize that a high index of suspicion should be raised in the differential diagnosis of transverse myelitis in endemic areas.

Mimics and rare presentations of pediatric demyelination.

This article reviews the features that should prompt consideration of diseases that mimic acquired demyelinating syndromes and multiple sclerosis using vignettes to highlight unusual clinical and radiologic features. Cases of transverse myelitis, spinal infarction, acute disseminated encephalomyelitis, fever-induced refractory epileptic encephalopathy in school-aged children, small-vessel vasculitis, Griscelli syndrome type 2, cysticercosis, vitamin B12 deficiency, and chronic relapsing inflammatory optic neuropathy are presented.

IL-12p40 deficiency leads to uncontrolled Trypanosoma cruzi dissemination in the spinal cord resulting in neuronal death and motor dysfunction.

Chagas' disease is a protozoosis caused by Trypanosoma cruzi that frequently shows severe chronic clinical complications of the heart or digestive system. Neurological disorders due to T. cruzi infection are also described in children and immunosuppressed hosts. We have previously reported that IL-12p40 knockout (KO) mice infected with the T. cruzi strain Sylvio X10/4 develop spinal cord neurodegenerative disease. Here, we further characterized neuropathology, parasite burden and inflammatory component associated to the fatal neurological disorder occurring in this mouse model. Forelimb paralysis in infected IL-12p40KO mice was associated with 60% (p<0.05) decrease in spinal cord neuronal density, glutamate accumulation (153%, p<0.05) and strong demyelization in lesion areas, mostly in those showing heavy protein nitrosylation, all denoting a neurotoxic degenerative profile. Quantification of T. cruzi 18S rRNA showed that parasite burden was controlled in the spinal cord of WT mice, decreasing from the fifth week after infection, but progressive parasite dissemination was observed in IL-12p40KO cords concurrent with significant accumulation of the astrocytic marker GFAP (317.0%, p<0.01) and 8-fold increase in macrophages/microglia (p<0.01), 36.3% (p<0.01) of which were infected. Similarly, mRNA levels for CD3, TNF-α, IFN-γ, iNOS, IL-10 and arginase I declined in WT spinal cords about the fourth or fifth week after infection, but kept increasing in IL-12p40KO mice. Interestingly, compared to WT tissue, lower mRNA levels for IFN-γ were observed in the IL-12p40KO spinal cords up to the fourth week of infection. Together the data suggest that impairments of parasite clearance mechanisms in IL-12p40KO mice elicit prolonged spinal cord inflammation that in turn leads to irreversible neurodegenerative lesions.

Quadriparalytic disseminated neurocysticercosis.

Cysticercosis is the most common parasitic infection of the central nervous system. Cysticercosis infrequently affects the spine, but when it does, it can present with symptoms similar to other more common spinal diseases. Here, the authors report a case of disseminated cysticercosis, with simultaneous involvement of brain and the spinal cord. Initially, the patient was misdiagnosed as tuberculoma on the basis of cerebrospinal fluid examination and CT scan of brain and was being treated with antitubercular therapy. Later on the patient developed quadriparesis which was investigated and diagnosed to be disseminated neurocysticercosis.

Isolated intradural-extramedullary spinal cysticercosis: a case report.

Spinal cysticercosis is an uncommon manifestation of neurocysticercosis (NCC). We present a case of isolated lumbar intradural-extramedullary NCC. The patient was treated successfully with the surgical removal of the cyst. Spinal NCC should be considered in the differential diagnosis in high-risk populations with new symptoms suggestive of a spinal mass lesion.

Neuroschistosomiasis due to Schistosoma haematobium presenting as spinal cord tumor.

Schistosomiasis is rarely encountered in the United States, but immigration and travel to endemic areas make it important to know its various presentations to improve diagnosis and treatment. We present our experience with a child with Schistosoma haematobium pseudotumor, initially diagnosed as a cord neoplasm.

Sparganosis mimicking an intramedullary tumor of the cervical cord.

Sparganosis is a rare parasitic infection caused by the migrating plerocercoid larva of the tapeworm Spirometra mansoni that rarely affects the central nervous system. When sparganosis involves the spinal cord, it often affects the thoracic area. Here we report a patient with sparganosis mimicking an intramedullary tumor of the cervical cord. A 51-year-old male presented with slowly progressive paresthesias in all extremities and left-sided motor weakness. MRI of the spinal cord revealed an enhancing lesion from C1 to C4 that was suggestive of an intramedullary tumor. The results of enzyme-linked immunosorbent assays of the cerebrospinal fluid were consistent with infection with Spirometra mansoni, and the larvae were surgically removed. Sparganosis may mimic an intramedullary tumor of the spinal cord and should be considered in the differential diagnosis of a cervical cord mass with an uncertain course.

Unusual location of hydatid cysts in pediatric patients.

OBJECTIVE/AIMS: To emphasize the importance of diagnosis and treatment of unusually localized hydatid cysts in pediatric cases. METHODS: Hydatid cyst patients of two departments were listed who had undergone surgery between January 2001 and December 2008. Of the 7 pediatric patients, 3 were chosen as the ones with unusual localization. Cyst removal with Dowling's technique was performed in 2 cases and total removal of the cyst wall was achieved after cyst aspiration in the other patient. RESULTS: Two patients did not show any signs of recurrence. Some of the cranial multiple cysts of the patient who had undergone her first surgery in another clinic with cyst rupture were successfully removed in our clinic. Six months later, she was admitted with spinal seedings. CONCLUSION: Hydatid cyst removal without rupture should be the surgical goal in all cases. Radiological evaluation is of utmost importance for differential diagnosis. When a cystic lesion is found in the central nervous system on radiological evaluation, hydatid disease must be considered in countries where the disease is endemic and surgery is to be planned emergently especially for pediatric cases with increased intracranial pressure. The study focuses on the strategy for the correct diagnosis and the appropriate treatment of unusually localized hydatid cysts.

Intradural extramedullary spinal hydatidosis: case report.

The parasitic tapeworm Echinococcus granulosis causes hydatid disease, which is rarely encountered in nonendemic regions. It is a progressive disease with serious morbidity risks. Rarely, these cysts are found in the spine. They are mainly found epidurally, originating from direct extension from pulmonary, abdominal or pelvic infestation. Nevertheless, the main mechanism for intradural involvement is not yet clear. Antihelminthic treatment should be administered for a long period following early decompressive surgery. We report a case of recurrent hydatid disease that presented unusual intradural dissemination. Prognosis for spinal hydatid disease remains very poor and comparable to that of a malignant neoplasm.

Toxoplasma gondii: the role of IFN-gamma, TNFRp55 and iNOS in inflammatory changes during infection.

In order to examine the role of IFN-gamma, TNFRp55 and iNOS in inflammatory reaction during toxoplasmosis, IFN-gamma(-/-), TNFRp55(-/-) and iNOS(-/-) mice were experimentally infected with Toxoplasma gondii ME-49 strain. The organs of the mice were evaluated for histology and immunohistochemistry in detection of tissue parasitism and iNOS positive cells. IFN-gamma(-/-) mice presented mild inflammation in peripheral organs associated with a high parasitism and mortality in the acute phase of infection. In contrast, the peripheral organs of WT, TNFRp55(-/-) and iNOS(-/-) mice, presented a significant inflammatory reaction and low tissue parasitism in the same period of infection. The inflammatory lesions and tissue parasitism were increased and more severe in the Central Nervous System (CNS) of TNFRp55(-/-) and iNOS(-/-) with a progression of infection, when compared to WT mice. In these knockout animals, the inflammatory changes were associated with low levels or no expression of iNOS in TNFRp55(-/-) and iNOS(-/-) mice, respectively.

Spinal hydatid cyst mimicking arachnoid cyst on magnetic resonance imaging.

BACKGROUND: Primary spinal hydatid cysts are uncommon and account for 1% of all cases of hydatid disease. Echinococcus granulosus is most often responsible for the cyst hydatid. Intradural, extramedullary involvement is rare. When the cysts do not demonstrate typical magnetic resonance imaging findings, the differential diagnosis is more complex. METHOD: Case report. FINDINGS: An isolated primary hydatid cyst of the spine in a 35-year-old man that appeared to be an arachnoid cyst on preoperative radiographic examination. CONCLUSION: Hydatid cysts that lack the typical radiographic appearance may be mistaken for arachnoid cysts. Misdiagnosis has serious implications for surgical intervention and long-term care.

A new species of myxozoan (Myxosporea) from the brain and spinal cord of rainbow trout (Oncorhynchus mykiss) from Idaho.

A new species of Myxosporea, Myxobolus neurotropus n. sp., is described from the brain and spinal cord of rainbow trout (Oncorhynchus mykiss) from Duncan Creek, Owyhee County, Idaho. Spores are oval, have 2 pyriform polar capsules, and possess a thick spore wall (sutural rim) with a short intracapsular offshoot. The mean spore dimensions are length 11.8 microm, width 10.8 microm, and thickness 8.8 microm. This myxozoan is compared to other described Myxobolus species found in cranial tissues of salmonids in terms of spore morphology and phylogenetic analysis. Because it is found in brain and spinal cord, it is encountered while performing screening tests for Myxobolus cerebralis, the causative agent of salmonid whirling disease. Where chronic inflammation and granulomatous lesions are associated with M. cerebralis, histological examination shows no host response to M. neurotropus n. sp. A diagnostic polymerase chain reaction (PCR) test is included as an aid in properly identifying the species.