Abstract

Background: Racemose neurocysticercosis (NCC) is a relatively rare form of NCC that describes the formation of cysts that appear as multiloculated, grape-like without scolices at the ventricles or basal subarachnoid region in patients infected by the tapeworm Taenia solium. Clinical manifestations vary and can occur up to decades after initial infection.

Case: A 38-year-old Hispanic male patient presented to the emergency room complaining of one-week intermittent, frontotemporal headache and feeling of pressure. He had a similar episode diagnosed as “viral meningitis” 13-years prior with recurrent headaches since then.  Initial Head CT demonstrated mild ventriculomegaly, diffuse sulcal effacement with suspicion for communicating hydrocephalus and increased intracranial pressure. Lumbar puncture demonstrated leukocytosis (190 total nucleated, 95% lymphocytes) and elevated protein (85 mg/dL). Subsequent Brain MRI/MRV showed a cystic lesion in the fourth ventricle highly suggestive of racemose NCC with obstructive hydrocephalus. Later cysticercosis IgG antibodies were positive. A dramatic clinical response to treatment with dexamethasone, followed by Albendazole 600 mg twice a day was observed. Neurology, neurosurgery, and infectious diseases teams agreed that it was prudent to withhold surgery and continue effective pharmacologic and anti-inflammatory therapy along with clinical and radiologic monitoring. 

Conclusions: Racemose NCC requires a high level of suspicion along with correct diagnostic imaging. It is necessary to further investigate unclear causes of acute hydrocephalus, as MR imaging is the superior modality to identify racemose NCC. Treatment for NCC depends on the stage, location of the cysts, and clinical presentation. A thorough and comprehensive history, appropriate diagnostic imaging and a multidisciplinary team consultation are necessary to provide the correct level of care.