G Model JIPH-683; No of Pages ARTICLE IN PRESS Journal of Infection and Public Health xxx (2017) xxx–xxx Contents lists available at ScienceDirect Journal of Infection and Public Health journal homepage: http://www.elsevier.com/locate/jiph Short Report Racemose neurocysticercosis Arushi G Saini a , Sameer Vyas b , Pratibha Singhi a,∗ a Pediatric Neurology and Neurodevelopment Unit, Advanced Pediatrics Centre, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India b Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India a r t i c l e i n f o Article history: Received 24 August 2016 Received in revised form October 2016 Accepted 18 November 2016 Keywords: Racemose Neurocysticercosis Intraventricular Hydrocephalus a b s t r a c t Racemose neurocysticercosis refers to the ‘aberrant proliferating cestode larvae” presenting as multiple, non-capsulated cystic membranes that bud exogenously giving a multilocular cystic appearance resembling a ‘bunch of grapes’ These are typically located in non-confining areas of brain such as cisterns and lack scolex, contrast-enhancement or edema We describe a 12-year-old boy with acute-onset headache, vomiting, drowsiness and irrelevant speech, irritability, meningismus, brisk muscle-stretch-reflexes and Babinski’s sign Magnetic resonance imaging brain revealed racemose neurocysticercosis He received ventriculo-peritoneal shunt, oral corticosteroids and albendazole for weeks Racemose cysts in neurocysticercosis are a rare presentation in children Treatment is difficult.Racemose neurocysticercosis refers to the ‘aberrant proliferating cestode larvae” presenting as multiple, non-capsulated cystic membranes that bud exogenously giving a multilocular cystic appearance resembling a ‘bunch of grapes’ These are typically located in non-confining areas of brain such as cisterns and lack scolex, contrast-enhancement or edema We describe a 12-year-old boy with acute-onset headache, vomiting, drowsiness and irrelevant speech, irritability, meningismus, brisk muscle-stretch-reflexes and Babinski’s sign Magnetic resonance imaging brain revealed racemose neurocysticercosis He received ventriculo-peritoneal shunt, oral corticosteroids and albendazole for weeks Racemose cysts in neurocysticercosis are a rare presentation in children Treatment is difficult © 2017 The Authors Published by Elsevier Limited This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Patient summary A 12-year-old boy presented with acute-onset, diffuse headache and non-projectile vomiting followed by progressive drowsiness and irrelevant speech There was no fever, seizure, visual problem or focal motor deficit He had been diagnosed with multiple parenchymal neurocysticercosis at the age of years and was treated with oral albendazole and corticosteroids He had remained asymptomatic till now Examination showed altered sensorium, irritability, meningismus, brisk muscle stretch reflexes and extensor plantar response bilaterally Contrast-enhanced computed tomography (CT) of brain showed non-communicating hydrocephalus (Fig 1) and a right ventriculo-peritoneal shunt was inserted Magnetic resonance imaging (MRI) of the brain revealed underlying intraventricuar and subarachnoid neurocysticercosis (Fig 2A–H) He received oral corticosteroids for weeks followed ∗ Corresponding author at: Department of Pediatrics and Chief Pediatric Neurology and Neurodevelopment, Advanced Pediatric Centre, PGIMER, Chandigarh, 160012, India Fax: +91 172 2744401; +91 172 2745078 E-mail address: doctorpratibhasinghi@gmail.com (P Singhi) by oral albendazole for weeks Repeat neuroimaging after year showed similar findings ‘Racemose neurocysticercosis’ an uncommon presentation that refers to ‘aberrant proliferating Taenia solium larvae’ presenting as multiple, non-capsulated cystic membranes that bud exogenously giving a multilocular cystic appearance, thus resembling a ‘bunch of grapes’ These cysts are typically seen in non-confining areas of the brain such as suprasellar, sylvian and quadrigeminal cisterns or around the rostral brainstem and usually lack scolex, contrastenhancement and edema Racemose neurocysticercosis may cause mass effect, cranial nerve entrapment or arachnoiditis resulting in meningeal inflammation and/or hydrocephalus and less commonly, small-vessel infarcts secondary to occlusive endarteritis These may be missed on CT scans and need MRI for correct diagnosis Lack of treatment efficacy after a first course of antiparasitic treatment is not uncommon and at times multiple courses are required for parasitic clearance Intraventricular neurocysticercosis may need neuro-endoscopic procedures to improve the outcome Racemose NCC is rarely seen in children and a high index of suspicion is needed for correct diagnosis http://dx.doi.org/10.1016/j.jiph.2016.11.019 1876-0341/© 2017 The Authors Published by Elsevier Limited This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/) Please cite this article in press as: Saini AG, et al Racemose neurocysticercosis J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.019 G Model JIPH-683; No of Pages ARTICLE IN PRESS A.G Saini et al / Journal of Infection and Public Health xxx (2017) xxx–xxx Fig Contrast-enhanced computed tomography scan of brain showing non-communicating hydrocephalus Fig A–H A Magnetic resonance imaging brain showing T2 (A and B), FLAIR (C and D), post-contrast T1 (E and F) axial sections showing multiple non-enhancing cystic lesions in the right pre-pontine and pre-medullary cistern consistent with neurocysticercosis (thin black arrow) These lesions are indenting and scalloping the brainstem, however no signal changes appreciated No diffusion restriction or susceptibility changes appreciated in the lesions Axial constructive interference in steady state (CISS) images (G) showing circumscribed, cystic lesion (arrow) in the anterior third ventricle and (H) shows disappearance of lesion in follow-up after months Funding No funding sources Competing interests None declared Ethical approval Not required Acknowledgements None Please cite this article in press as: Saini AG, et al Racemose neurocysticercosis J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.019 ... approval Not required Acknowledgements None Please cite this article in press as: Saini AG, et al Racemose neurocysticercosis J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.019... non-enhancing cystic lesions in the right pre-pontine and pre-medullary cistern consistent with neurocysticercosis (thin black arrow) These lesions are indenting and scalloping the brainstem,