Three years ago in Boston, the family went into chaos in the wee hours of the morning. The man who had slept soundly next to his wife a moment ago was cramped on the floor, and no one knew why.
He was confused, uttering nonsensical words, and tried to resist being taken by ambulance to Massachusetts General Hospital. There, doctors, through an arduous diagnosis process, found an unwanted stranger.
In the studies, the heartbeat and breathing of the unfortunate man were slightly elevated, but no abnormalities were observed in the toxicology and chest X-rays. There was no physical evidence to suggest an underlying chronic disease, no medical history or unusual behavior prior to the event, and no family history of neurological problems.
“The patient also had blood in his mouth, presumably from biting his tongue,” Dr. Andrew Cole writes in a recently published case report.
The 38-year-old man received lorazepam for the seizures, but it took even more work to find out what was originally causing them.
Several conditions can lead to seizures or symptoms that look like them. Anything that interferes with blood circulation in the brain can cause them, so it is important to check your entire circulatory system. Tests revealed that a man’s liver, which regulates the chemicals in our bloodstream, and the kidneys, which remove waste products from the blood and regulate blood pressure, both function properly.
Also, momentary blood loss to the brain (ischemic attacks), drugs, migraines, and psychiatric events can cause seizure-like symptoms, but toxicological tests and the fact that the man had previously been completely healthy ruled them out.
“Getting a clinical history is key,” Cole explains. “The most powerful tool for estimating a potential scene is additional information.”
The patient’s history provided a clue. He had moved from a rural area in Guatemala 20 years ago.
Brain scans revealed three calcified lesions. Based on their presentation and the patient’s history, doctors concluded that they were cysts belonging to the parasitic worm (Taenia solium). These white, ribbon-like worms rely on human hosts to reach the adult stage of their life cycle, where they catch the small intestine with dozens of small hooks.
Here, the worms enjoy the surrounding nutrients and can grow to a staggering eight meters in length. This is the stage where they can reproduce sexually if they have good luck – otherwise they will reproduce asexually. Their eggs carry our feces to the rest of the world. They can then survive in the environment for up to two months as eggs in the hope that another animal will eat them.
Pigs are the most common intermediate host, but sometimes other people or even the person originally infected eats tapeworm eggs. They hatch in the gut of their eater and the resulting larva entered the bloodstream, preferably nesting in tasty pork muscles, which can then transport them back to people who have eaten undercooked meat.
However, the resulting cysts formed by the larvae can develop in any organ, and they are the ones that cause the most serious problems – especially if they settle in the brain.
This condition is called neurocystic sucrose and is a leading cause of acquired epilepsy in many parts of the world – including Latin America and sub-Saharan Africa. In the United States alone, thousands of people are believed to file similar cases every year.
Neurocystic sclerosis is a preventable disease, but despite its prevalence and severity, relatively few resources have been devoted to its control, which is why the CDC classified it as a neglected tropical disease.
Preventive measures include careful hand washing, safe cooking and handling of meat, and prompt care for people with intestinal tapeworms.
Some cases of neurocystic sclerosis require surgery to remove a problematic cyst from the brain, such as the recent case of a 25-year-old Australian woman who experienced constant headaches and blurred vision. Because cysts can form in different parts of the brain, symptoms can vary greatly.
In this case, the man was treated with an anti-inflammatory, anticonvulsant, and two antiparasitic drugs. He was discharged from the hospital without symptoms after five days and remains seizure-free after three years.
However, he is likely to continue to use anticonvulsants.
“The question of when the medication will be stopped is problematic because the calcified lesion will last forever,” Cole says.
This case study was reported in New England Journal of Medicine.