Cysticercosis differential diagnosis: Difference between revisions

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* Headaches are the most common symptom. Usually, headaches occur on the same side of the abscess and tend to be severe (not responding to analgesics).
* Headaches are the most common symptom. Usually, headaches occur on the same side of the abscess and tend to be severe (not responding to analgesics).


* Fever is not  a reliable sign .(2)
* Fever is not  a reliable sign.<ref name="pmid25075836">{{cite journal |vauthors=Brouwer MC, Tunkel AR, McKhann GM, van de Beek D |title=Brain abscess |journal=N. Engl. J. Med. |volume=371 |issue=5 |pages=447–56 |year=2014 |pmid=25075836 |doi=10.1056/NEJMra1301635 |url=}}</ref>
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*Lumbar puncture is contraindicated but when done, it was variable between patients.
*Lumbar puncture is contraindicated but when done, it was variable between patients.
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* Contrast enhances CT provides rapid assessment of the size and number of the abscesses.
* Contrast enhances CT provides rapid assessment of the size and number of the abscesses.


* MRI: Diffusion-weighted imaging (DWI) MRI can differentiate brain abscesses from cystic brain lesions with sensitivity and specificity of 96% (3)
* MRI: Diffusion-weighted imaging (DWI) MRI can differentiate brain abscesses from cystic brain lesions with sensitivity and specificity of 96%.<ref name="urlBrain Abscess — NEJM">{{cite web |url=http://www.nejm.org/doi/full/10.1056/NEJMra1301635 |title=Brain Abscess — NEJM |format= |work= |accessdate=}}</ref>


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* Most common presenting symptom is dull aching
* Most common presenting symptom is dull aching
headache.
headache.
* Usually, it's associated with other symptoms of increased intracranial pressure (ICP) as seizures, visual disturbances, nausea, and vomiting. (4)
* Usually, it's associated with other symptoms of increased intracranial pressure (ICP) as seizures, visual disturbances, nausea, and vomiting.<ref name="urlPrimary Brain Tumors in Adults - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2008/0515/p1423.html |title=Primary Brain Tumors in Adults - American Family Physician |format= |work= |accessdate=}}</ref>
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* CT may be used in localizing the tumor and getting a rough estimate on the dimensions.
* CT may be used in localizing the tumor and getting a rough estimate on the dimensions.
* MRI: Gadolinium-enhanced MRI is the preferred imaging modality for assessing the extension of the tumor and its exact location. (4)
* MRI: Gadolinium-enhanced MRI is the preferred imaging modality for assessing the extension of the tumor and its exact location.<ref name="urlPrimary Brain Tumors in Adults - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2008/0515/p1423.html |title=Primary Brain Tumors in Adults - American Family Physician |format= |work= |accessdate=}}</ref>
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|Brain tuberculoma
|Brain tuberculoma
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* Presentations are usually due to the pressure effect, not the T.B. bacilli.
* Presentations are usually due to the pressure effect, not the T.B. bacilli.


* Presenting symptoms and signs in order of occurrence: (5)
* Presenting symptoms and signs in order of occurrence:<ref name="urlThe Journal of Association of Chest Physicians - Tuberculoma of the brain - A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF">{{cite web |url=http://www.jacpjournal.org/downloadpdf.asp?issn=2320-8775;year=2015;volume=3;issue=1;spage=3;epage=8;aulast=Mukherjee;type=2 |title=The Journal of Association of Chest Physicians - Tuberculoma of the brain - A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF |format= |work= |accessdate=}}</ref>
# Episodes of focal seizures  
# Episodes of focal seizures  
# Signs of increased intracranial pressure
# Signs of increased intracranial pressure
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|Neurosarcoidosis
|Neurosarcoidosis
|70% of the patients present with the neurological symptoms rather than the presentation of systemic disease. Common presentations are:(6)
|70% of the patients present with the neurological symptoms rather than the presentation of systemic disease. Common presentations are:<ref name="urlNeurosarcoidosis">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975794/ |title=Neurosarcoidosis |format= |work= |accessdate=}}</ref>


# Cranial neuropathies: Facial palsy is the most common presentation.
# Cranial neuropathies: Facial palsy is the most common presentation.
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* Serum ACE levels are elevated in 25% of the cases
* Serum ACE levels are elevated in 25% of the cases


* Lumbar puncture shows elevated spinal cord proteins together with mild-moderate pleocytosis. It is usually accompanied by oligoclonal bands.(6)
* Lumbar puncture shows elevated spinal cord proteins together with mild-moderate pleocytosis. It is usually accompanied by oligoclonal bands.<ref name="urlNeurosarcoidosis">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975794/ |title=Neurosarcoidosis |format= |work= |accessdate=}}</ref>
|MRI with contrast shows enhancement of the inflamed areas (i.e. cranial nerves, meninges or HPO axis)
|MRI with contrast shows enhancement of the inflamed areas (i.e. cranial nerves, meninges or HPO axis)
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* Diagnosis made usually between 8-16 years (rarely in adulthood)  
* Diagnosis made usually between 8-16 years (rarely in adulthood)  
* Wide range of symptoms from being asymptomatic to decreased vision and strabismus.
* Wide range of symptoms from being asymptomatic to decreased vision and strabismus.
* Decreased visual acuity at initial presentation has a poor prognosis. (7)
* Decreased visual acuity at initial presentation has a poor prognosis. <ref name="urlHow to Diagnose and Manage Coats’ Disease">{{cite web |url=https://www.reviewofophthalmology.com/article/how-to-diagnose-and-manage-coatsand8217-disease-42782 |title=How to Diagnose and Manage Coats’ Disease |format= |work= |accessdate=}}</ref>
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* Fundus examination reveals vascular lesions and exudates.
* Fundus examination reveals vascular lesions and exudates.
* Fluorescein angiography is the best method to visualize the lesions.
* Fluorescein angiography is the best method to visualize the lesions.
* CT and MRI are reserved for atypical cases. (7)
* CT and MRI are reserved for atypical cases.<ref name="urlHow to Diagnose and Manage Coats’ Disease">{{cite web |url=https://www.reviewofophthalmology.com/article/how-to-diagnose-and-manage-coatsand8217-disease-42782 |title=How to Diagnose and Manage Coats’ Disease |format= |work= |accessdate=}}</ref>
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|Retinal Detachment
|Retinal Detachment
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* Most common presenting symptoms are photophobia and floaters
* Most common presenting symptoms are photophobia and floaters
* Visual field defects (described as curtain falling from periphery to the center) (8)
* Visual field defects (described as curtain falling from periphery to the center)<ref name="urlManagement of retinal detachment: a guide for non-ophthalmologists">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2405853/ |title=Management of retinal detachment: a guide for non-ophthalmologists |format= |work= |accessdate=}}</ref>
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* Ophthalmoscope is not reliable in detecting retinal detachment as there might be associated hemorrhage
* Ophthalmoscope is not reliable in detecting retinal detachment as there might be associated hemorrhage
* Ultrasound can be used to identify and localize the detachment. (8)
* Ultrasound can be used to identify and localize the detachment.<ref name="urlManagement of retinal detachment: a guide for non-ophthalmologists">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2405853/ |title=Management of retinal detachment: a guide for non-ophthalmologists |format= |work= |accessdate=}}</ref>
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|Thyroid Ophthalmopathy
|Thyroid Ophthalmopathy
|The hallmark is Eye protrusion, photophobia, lacrimation and later in the disease, diminished eye motility.(9)
|The hallmark is Eye protrusion, photophobia, lacrimation and later in the disease, diminished eye motility.<ref name="urlThyroid Ophthalmopathy - EyeWiki">{{cite web |url=http://eyewiki.aao.org/Thyroid_Ophthalmopathy |title=Thyroid Ophthalmopathy - EyeWiki |format= |work= |accessdate=}}</ref>
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CT: shows inflamed muscle and free tendon from inflammation
CT: shows inflamed muscle and free tendon from inflammation


MRI: shows periorbital fat expansion, increased water content of the muscles as a result of the inflammation.(9)
MRI: shows periorbital fat expansion, increased water content of the muscles as a result of the inflammation.<ref name="urlThyroid Ophthalmopathy - EyeWiki">{{cite web |url=http://eyewiki.aao.org/Thyroid_Ophthalmopathy |title=Thyroid Ophthalmopathy - EyeWiki |format= |work= |accessdate=}}</ref>
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|Retinoblastoma
|Retinoblastoma
|The most prominent sign is leukocoria, followed by strabismus
|The most prominent sign is leukocoria, followed by strabismus


The patient also may present with buphthalmos, corneal clouding and eye tearing.(10)
The patient also may present with buphthalmos, corneal clouding and eye tearing.<ref name="urlc.ymcdn.com">{{cite web |url=https://c.ymcdn.com/sites/www.covd.org/resource/resmgr/VDR_1-1/VDR1-1_article_Kollodge_Web.pdf+ |title=c.ymcdn.com |format= |work= |accessdate=}}</ref>
|Ultrasound: can detect the tumor as a result of the calcifications inside.
|Ultrasound: can detect the tumor as a result of the calcifications inside.


MRI: assess sellar and parasellar regions .. it can also detect extraocular spread of the tumor.(10)
MRI: assess sellar and parasellar regions .. it can also detect extraocular spread of the tumor.<ref name="urlc.ymcdn.com">{{cite web |url=https://c.ymcdn.com/sites/www.covd.org/resource/resmgr/VDR_1-1/VDR1-1_article_Kollodge_Web.pdf+ |title=c.ymcdn.com |format= |work= |accessdate=}}</ref>


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Revision as of 04:05, 14 April 2017

Cysticercosis Microchapters

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Overview

Cysticercosis must be differentiated from other diseases that cause brain and ocular cyst lesions.

Differentiating neurocysticercosis from other brain cyst lesions
Disease Prominent clinical features Lab findings Radiological findings
Neurocysticercosis
  • Parenchymal lesions: Presentation depends on the site and number of lesions.

Seizures are the most common presentation. It is mostly focal but can have a secondary generalization.

Lab findings are nonspecific.
Brain abscess
  • Headaches are the most common symptom. Usually, headaches occur on the same side of the abscess and tend to be severe (not responding to analgesics).
  • Fever is not a reliable sign.[1]
  • Lumbar puncture is contraindicated but when done, it was variable between patients.
  • Culture from the CT-guided aspirated lesion helps in identifying the causative agent.
  • Contrast enhances CT provides rapid assessment of the size and number of the abscesses.
  • MRI: Diffusion-weighted imaging (DWI) MRI can differentiate brain abscesses from cystic brain lesions with sensitivity and specificity of 96%.[2]
Brain tumors
  • Most common presenting symptom is dull aching

headache.

  • Usually, it's associated with other symptoms of increased intracranial pressure (ICP) as seizures, visual disturbances, nausea, and vomiting.[3]
  • CT may be used in localizing the tumor and getting a rough estimate on the dimensions.
  • MRI: Gadolinium-enhanced MRI is the preferred imaging modality for assessing the extension of the tumor and its exact location.[3]
Brain tuberculoma
  • Brain tuberculomas has insidious onset of symptoms as compared to tuberculous meningitis.
  • Presentations are usually due to the pressure effect, not the T.B. bacilli.
  • Presenting symptoms and signs in order of occurrence:[4]
  1. Episodes of focal seizures
  2. Signs of increased intracranial pressure
  3. Focal neurologic deficits.
 T.B. should be investigated everywhere else in the body (e.g. peripheral lymphadenopathy, sputum and blood culture)
  • CT: Contrast-enhanced CT scan shows a ring enhancing lesion surrounded by an area of hypodensity (cerebritis) and the resulting mass effect.
  • MRI: Better than CT scan in assessing the site and size of the tuberculoma. Gadolinium-enhanced MRI shows a ring enhancing lesion between 1-5 cm in size (In NCC, the wall is thicker, calcifications are eccentric and the diameter is less than 2 cm)
Neurosarcoidosis 70% of the patients present with the neurological symptoms rather than the presentation of systemic disease. Common presentations are:[5]
  1. Cranial neuropathies: Facial palsy is the most common presentation.
  2. Meningeal involvement: diffuse meningeal inflammation can cause diffuse basilar polyneuropathy in 40% of the patients. with neurosarcoidosis.
  3. Inflammatory spinal cord disease: Inflammatory span usually more than 3 spinal cord segments which helps to differentiate it from Multiple sclerosis.
  4. Peripheral neuropathy: Asymmetric polyneuropathy or mononeuritis multiplex. It may also manifest as GBS like presentation.
  5. HPO axis involvement: may present as diabetes inspidus. More than 50% of the cases have no radiological signs.
  • Noninvasive tests have low sensitivity and specificity.
  • Serum ACE levels are elevated in 25% of the cases
  • Lumbar puncture shows elevated spinal cord proteins together with mild-moderate pleocytosis. It is usually accompanied by oligoclonal bands.[5]
 MRI with contrast shows enhancement of the inflamed areas (i.e. cranial nerves, meninges or HPO axis)
Differentiating ocular cysticercosis from other ocular lesions
Disease Prominent clinical feature Radiological findings
Ocular cysticercosis
Coats disease
  • Diagnosis made usually between 8-16 years (rarely in adulthood)
  • Wide range of symptoms from being asymptomatic to decreased vision and strabismus.
  • Decreased visual acuity at initial presentation has a poor prognosis. [6]
  • Fundus examination reveals vascular lesions and exudates.
  • Fluorescein angiography is the best method to visualize the lesions.
  • CT and MRI are reserved for atypical cases.[6]
Retinal Detachment
  • Most common presenting symptoms are photophobia and floaters
  • Visual field defects (described as curtain falling from periphery to the center)[7]
  • Ophthalmoscope is not reliable in detecting retinal detachment as there might be associated hemorrhage
  • Ultrasound can be used to identify and localize the detachment.[7]
Thyroid Ophthalmopathy The hallmark is Eye protrusion, photophobia, lacrimation and later in the disease, diminished eye motility.[8]

Ultrasonography: inflamed thickened extraocular muscles.

CT: shows inflamed muscle and free tendon from inflammation

MRI: shows periorbital fat expansion, increased water content of the muscles as a result of the inflammation.[8]

Retinoblastoma The most prominent sign is leukocoria, followed by strabismus

The patient also may present with buphthalmos, corneal clouding and eye tearing.[9]

Ultrasound: can detect the tumor as a result of the calcifications inside.

MRI: assess sellar and parasellar regions .. it can also detect extraocular spread of the tumor.[9]

References

  1. ↑ Brouwer MC, Tunkel AR, McKhann GM, van de Beek D (2014). "Brain abscess". N. Engl. J. Med. 371 (5): 447–56. doi:10.1056/NEJMra1301635. PMID 25075836.
  2. ↑ "Brain Abscess — NEJM".
  3. ↑ 3.0 3.1 "Primary Brain Tumors in Adults - American Family Physician".
  4. ↑ "The Journal of Association of Chest Physicians - Tuberculoma of the brain - A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF".
  5. ↑ 5.0 5.1 "Neurosarcoidosis".
  6. ↑ 6.0 6.1 "How to Diagnose and Manage Coats' Disease".
  7. ↑ 7.0 7.1 "Management of retinal detachment: a guide for non-ophthalmologists".
  8. ↑ 8.0 8.1 "Thyroid Ophthalmopathy - EyeWiki".
  9. ↑ 9.0 9.1 "c.ymcdn.com".


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