Cyst or cysticercus?March 7, 2019
Rajesh (name changed), a 10-year-old boy from Kolhapur, was a studious kid. However, lately, he had started reading his books while lying down. His father, who was the principal of a local school, was unhappy seeing these reading habits and would keep nagging his son to sit in an appropriate upright position while reading. Rajesh, however, would get headaches while reading in a sitting position and for the past month or two, he was able to read for longer periods without a headache only if reading while lying down on his back. The arguments continued between father and son for several months until Rajesh’s condition worsened, and his headaches become more severe and accompanied with vomiting and visual blurring. Rajesh’s father then realized there may be more to his reading habits and had to seek medical advice from a paediatrician. The paediatrician recommended an ophthalmic checkup and a CT scan of the brain. Funduscopic examination revealed papilledema and the CT scan showed a cyst in the third ventricle. Rajesh was then referred to Dr Uday Andar, a paediatric neurosurgeon at Bombay Hospital, Mumbai, for further management. Dr Andar recommended an MRI brain scan which showed a pedunculated cyst within the third ventricular cavity. Surgery was immediately scheduled, and the cyst was excised micro endoscopically without any complications.
Interestingly, the cyst turned out to be cysticercus. Cysticercus is a tapeworm belonging to the genus Taenia. They look like a small sac-like vesicle similar to a bladder. These tapeworms commonly reside in the muscles of pigs and cattle and their eggs are typically ingested with raw or undercooked contaminated pork or beef or through raw contaminated vegetables in salads. The eggs hatch inside the human host and can move anywhere in the body via the bloodstream, including the brain. Brain infections can be especially dangerous as they may lead to neurocysticercosis, which is one of the major causes of acquired epilepsy. Depending on the location of the cyst in the brain, it may even result in death in case of high pressure due to hydrocephalus. Cysticercus is likely to be present at multiple locations, and upon further investigation, Rajesh was found to have cysticercus in the leg calf muscles as well. This is typically visualized as lumps under the skin.
Because of the pedunculated nature of the cyst in the third ventricle of the brain, whenever Rajesh would sit and bend forward to read, the foramen of Monro would get blocked and cerebrospinal fluid would collect in the ventricles increasing the intracranial pressure and causing headaches. Whenever Rajesh was in a supine position, the cyst would move backwards and the block would be released, allowing the cerebrospinal fluid to flow freely and relieve the headache. For Rajesh, this condition worsened as the cyst enlarged, and finally, when the cyst was large enough to block the ventricles, it resulted in hydrocephalus and consequently visual blurring. Had it been left untreated much longer, it could have resulted in death due to the increase in intracranial pressure.
Cysticercus is not uncommon in India, especially in a city like Mumbai, where vegetables are grown along the railway tracks and exposed to all sorts of human and animal excreta. Dr Andar advocates that both vegetables and meats be thoroughly cleaned and cooked well before being consumed.
Often, early diagnosis is missed in children, either because the child does not complain, or the parents ignore minor complaints until the condition worsens.
Dr Andar advises that ‘children complaining of headaches for more than 7-10 days be carefully investigated. Though there is no literature to support this, clinical experience teaches one to be more prudent than sorry and investigate such children early on.’ With the current technological advances in the field of non-invasive investigations such as CT scans and MRIs, it is definitely advisable to investigate early and thereby prevent catastrophes and the risk of high morbidity. In Rajesh’s case, it turned out to be a cysticercus. However, it could have been a tumour. Early diagnosis and treatment is essential in such cases.