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“So does she still needthe steroids?”

Wednesday ID Case Conference

Christopher Hurt, MDApril 4, 2007

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HPIHPI

• NL is a 56yo Latina transferred for SAH

• Presented with N/V, “dizziness” and blurry vision

• Initially in outside ED was OK but rapidly becameobtunded; ETT for airway protection

• Head CT showed fresh blood, sent to UNC forNSG eval

• Add’l imaging at UNC showed extensive bleedinto basal cistern, bilateral Sylvian fissues, andalso IVH with pooling in temporal horns

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HPI, contHPI, cont’’dd

• Taken to angio suite for eval of possible aneurysmfor intervention

• Fusiform aneurysm of L vertebral artery identified

• No coiling done

• Started on phenytoin and nimodipine, EVD placed

• MRI/MRA obtained to look for other aneurysms

• No recent constitutional symptoms – had been inUSOH up until this time

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PMHxPMHx//PSHxPSHx

• HTN

• T2DM, as a new diagnosis on admission to UNC

• No prior surgical history

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SocHxSocHx

• Originally from Mexico; undocumented

• Lives in Mount Olive, NC with extended family

• Works as housekeeper

• Unknown pet/animal exposures

• Unknown environmental exposures

• Unknown exposures to children

• Sexual history unknown

• No recent travel outside NC

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FHxFHx

• UTO

Meds, AllergiesMeds, Allergies• No o/p meds• Hospital meds:

» Amlodipine» Atorvastatin» Docusate» Famotidine» Nimodipine» Phenytoin» Propofol» Labetalol PRN» RISS

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PExPEx

Gen: Intubated, sedated,unarousable to voice

HEENT: NCAT. EVD present.Anicteric, noninjected OU.

Neck: UTA given ETTChest: CTAB anterolaterally,

coarse overallCV: RRR, no m/r/g. S1/S2.

Abd: Soft, NTND. NABS.Ext: Warm/dry, no c/c/e x4.Skin: No petechiae, rashes,

ecchymoses. No stigmataof IE peripherally.

Neuro: PERRL. Gag intact.UTA other neuro findingsgiven sedation.

Tm 38.6° HR 110 BP 139/75 RR 19 96%40Fi, vent

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LabsLabs

11.6

3417 182

145

3.4

116

21

7

0.5113

AST, ALT normalAφ 150 - GGT 103

PBCx pendingUCx pendingCSF from EVD pending

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More pretty picturesMore pretty pictureswere obtainedwere obtained……

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Inflammatory aneurysmInflammatory aneurysmfrom from neurocysticercosisneurocysticercosis

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Hospital CourseHospital Course• Serum neurocysticercosis WB sent; was negative• Primed with dexamethasone in advance of

empiric antihelminthic therapy• Neuro status tenuous, per NSG team• Attempts at clamping EVD with limited success• Taken to angio suite and had L vertebral artery

“sacrificed” with coiling• Treatment with albendazole deferred by ID team,

given potential for catastrophic outcome(s)• NSG pressed for treating, but never did• Now convalescing on PM&R service, doing well

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Taenia soliumTaenia solium• Humans both int, definitive host• Pigs eat vegetation

contaminated w/eggs or gravidproglottids

• Oncospheres hatch in bowel,invade wall, migrate to striatedmuscle or brain, encyst

• Cysticerci ingested inundercooked, infected pork

• Adult tapeworms in human gut

http://www.dpd.cdc.gov/DPDx/HTML/Taeniasis.htm

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NeurocysticerciNeurocysticerci• Made up of scolex and

vesicular wall• Viable cysts measure ~10mm• Tend to lodge in basal ganglia,

cortex bc of vascular supply• Subarachnoid cysts lodge in

cortical sulci or in cisterns• After long period, scolices lost

and dia grows, up to 50mm(esp. cisternal/subarachnoid)

• Racemose form = grapelike

Nonviable cyst(dead scolex;

viscous, turbid fluid)

Sotelo J, et al. Neurosurg Focus 2002;12(6):1-7

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Aneurysms from NCC?Aneurysms from NCC?• Case-reports• Presumed from inflammatory exudate coalescing

around vessels in dependent portions of skull» Entrapment of vessel in debris / material» Vascular wall weakness, dilatation… then, POP!

• Outcomes good in reported cases

Soto-Hernandez J, et al. Neurosurgery 1996;38(1):197-200Huang P, et al. Neurosurgery 2000;47(2):466-468

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Treatment of Treatment of subarachnoid subarachnoid NCCNCC• 36 patients with subarachnoid NCC randomly to

dexamethasone 8mg iv q8h for 4d, plusalbendazole on day 5:» 15mg/kg/d for 8d» 30mg/kg/d for 8d

• Marked clinical improvement on just steroids• Larger cyst reduction on MRI at 90, 180d at

higher-dosing• Single-course insufficient to treat intraventricular

or giant cysts• Steroids x3 to 6 mos after albendazole

Gongora-Rivera F, et al. Neurology 2006;66(3):436-438

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