|Year : 2020 | Volume
| Issue : 1 | Page : 35-37
Diagnosis of neuroschistosomiasis: How to overcome this challenge
Ijaz Kamal1, Ahmed Abdallah1, Madeha Khalid1, Ahmedelmustafa Musa2, Abdel Naser Elzouki1
1 Department of General Internal Medicine, Hamad General Hospital, Doha, Qatar
2 Department of Radiology, Hamad General Hospital, Doha, Qatar
|Date of Submission||10-Dec-2019|
|Date of Acceptance||29-Jan-2020|
|Date of Web Publication||12-Mar-2020|
Dr. Ijaz Kamal
Department of General Internal Medicine, Hamad General Hospital, Post Box No. 3050. Doha
Source of Support: None, Conflict of Interest: None
We report the case of a 25-year-old female from the Philippines who presents with seizure and left-sided body weakness. Initial magnetic resonance imaging showed cortical mass lesion suggestive of tumor or neuroschistosomiasis based on her ethnicity. This study aimed to confirm the diagnosis which can be done with direct brain biopsy which is associated with complications and rule out other causes such as tumor. The identification of schistosome eggs in a stool or urine sample is the gold standard for the diagnosis of schistosomiasis. However, the alternative model for the diagnosis of neuroschistosomiasis requires the detection of infection at an extraneural site which is suitable for biopsy together with laboratory and imaging evidence. This approach will help to avoid direct brain biopsy and its associated complications.
Keywords: Brain biopsy, magnetic resonance imaging, neuroschistosomiasis, schistosomiasis
|How to cite this article:|
Kamal I, Abdallah A, Khalid M, Musa A, Elzouki AN. Diagnosis of neuroschistosomiasis: How to overcome this challenge. Libyan J Med Sci 2020;4:35-7
|How to cite this URL:|
Kamal I, Abdallah A, Khalid M, Musa A, Elzouki AN. Diagnosis of neuroschistosomiasis: How to overcome this challenge. Libyan J Med Sci [serial online] 2020 [cited 2020 May 29];4:35-7. Available from: http://www.ljmsonline.com/text.asp?2020/4/1/35/280568
| Introduction|| |
Neuroschistosomiasis can affect both spinal cord and the brain, with cerebral disease is less common than myelopathy. The disease is secondary to adult worm embolization to cerebral microcirculation with the release of eggs which lead to an eosinophilic inflammatory granulomatous reaction that results in local tissue damage and scar formation. Neuroschistosomiasis can present as a motor or sensory impairment, seizure, or cerebellar syndrome. The diagnosis of neuroschistosomiasis is confirmed by direct evidence of the central nervous system infection either by brain biopsy or positive antibody titer or polymerase chain reaction (PCR) from the cerebrospinal fluid (CSF). The brain biopsy is always challenging due to the association with the central nervous system complications., The alternative way to confirm the diagnosis is to look for the involvement of extraneural site with the help of imaging and then get a biopsy of the extraneural site in a patient with suspected neuroschistosomiasis. We report the case of a 25-year-old female with suspected neuroschistosomiasis, where diagnosed was made with the help of imaging, serology, and confirmed with extraneural site biopsy.
| Case Report|| |
A 25-year-old female from the Philippines presented with left-sided body weakness and numbness after two episodes of generalized tonic–clonic seizures followed by postictal confusion. She was previously healthy. There was no history of epilepsy or any other significant illness in her family. She is working as a housemaid. She is nonsmoker and does not drink alcohol. She was not taking any medications and not using any recreational drugs. On neurological examination, she was alert and responsive with the power of 4/5 on the left side. Tone and reflexes were normal with equivocal planters. She had a normal sensation. She was admitted as the case of seizure with left side hemiparesis and was started on anticonvulsant medication. Initial blood workup, including complete blood count, coagulation profile, liver, and renal function tests, was normal. Computed tomography (CT) of the brain showed right-sided high parietal parasagittal area of low-attenuation density suggestive of edema. CT angiogram showed findings that suggestive of underlying mass lesion or arteriovenous malformation. Perfusion CT of the brain showed no mismatched perfusion defect. Power improved to 5/5 after admission, and she remained asymptomatic during her hospital stay; magnetic resonance imaging (MRI) was done [Figure 1] which demonstrated right posterior frontal parasagittal adjacent cortical lesions with surrounding vasogenic edema causing effacement of adjacent cortical sulci. Differential diagnosis includes the possibility of parasitic granulomas, particularly schistosomiasis based on her ethnicity apart from tumor and lymphoma. CSF analysis was normal with normal cell count and protein level. Her HIV test was negative. Urine and stool analysis for ova and parasite was negative. Serum Schistosoma antibody was positive with titer of 1:160. Keeping in view the risks of brain biopsy, CT chest, abdomen, and pelvis were done to look for any suitable extraneural site for biopsy. On CT abdomen and pelvis, an enhancing soft-tissue nodule at the left anterolateral urinary bladder wall with no calcification was found which was associated with some atrophic changes and subcapsular calcification in the right lobe of the liver that might represent the sequela of old infectious process. Cystoscopy-guided urinary bladder biopsy was done which demonstrated schistosomiasis-related cystitis with a large number of eosinophils and was negative for malignancy. The patient was started on treatment, including prednisolone with praziquantel and with anticonvulsant medication. She was discharged home with follow-up MRI brain. Repeat MRI after 3 weeks showed interval reduction in the size of the enhancing lesion in the right medial frontal parasagittal region with interval reduction in the perilesional vasogenic edema [Figure 2].
|Figure 1: Pretreatment magnetic resonance imaging of the brain shows right posterior frontal parasagittal adjacent two cortical lesions with surrounding vasogenic edema causing effacement of adjacent cortical sulci|
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|Figure 2: Repeat magnetic resonance imaging of the brain posttreatment showing interval reduction in size of the enhancing lesion in the right medial frontal parasagittal region with interval reduction in the perilesional vasogenic edema|
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| Discussion|| |
Schistosomiasis is a tropical parasitic disease that is found in endemic areas such as Africa and the Philippines. The most common cause is Schistosoma japonicum due to the small size of the eggs which make it easy to migrate to the brain. Neuroschistosomiasis can affect the brain or spinal cord. It occurs as an end result of eosinophilic granulomatous reaction caused by Th-2 cells immune response that is induced by the protein produced by eggs which eventually leads to tissue distraction, fibrosis, and scarring. MRI is the standard imaging technique for the diagnosis with typical findings of single or multiple hyperintense lesions with a nodular appearance on postcontrast enhancement. The identification of schistosome eggs in a stool or urine sample is the gold standard for the diagnosis of schistosomiasis which can used for species identification and to measure the parasite burden. Serologic tests are a useful diagnostic tool in the absence of egg detection; however, due to high false-positive results, serology is not recommended for the diagnosis. Biopsy is a useful diagnostic tool in cases of atypical disease manifestations with the absence of clear laboratory evidence, which will show schistosome eggs surrounded by granuloma. The diagnosis of neuroschistosomiasis can be challenging due to the high risk associated with brain biopsy., Therefore, in highly suspected patient, based on ethnicity, travel, and characteristic MRI findings, a thorough search for extraneural sites for biopsy will confirm the diagnosis. This will prevent the need for unnecessary brain biopsy which is associated with serious complications such as intracranial hemorrhage and operative infection.
| Conclusion|| |
The diagnosis of neuroschistosomiasis requires the laboratory detection of infection at an extraneural site together with clinical and radiographic evidence of neurologic involvement. Alternatively, neuroschistosomiasis can be diagnosed by more aggressive approach like a biopsy of a brain lesion or to check CSF PCR depending on the availability of facility.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ferrari TC, Moreira PR, Cunha AS. Clinical characterization of neuroschistosomiasis due to Schistosoma mansoni
and its treatment. Acta Trop 2008;108:89-97.
Scrimgeour EM, Gajdusek DC. Involvement of the central nervous system in Schistosoma mansoni
and S. haematobium infection. A review. Brain 1985;108 (Pt 4):1023-38.
Carod-Artal FJ. Neurological complications of Schistosoma infection. Trans R Soc Trop Med Hyg 2008;102:107-16.
Ferrari TC. A laboratory test for the diagnosis of neuroschistosomiasis. Neurol Res 2010;32:252-62.
Malone H, Yang J, Hershman DL, Wright JD, Bruce JN, Neugut AI. Complications following stereotactic needle biopsy of intracranial tumors. World Neurosurg 2015;84:1084-9.
Nascimento-Carvalho CM, Moreno-Carvalho OA. Neuroschistosomiasis due to Schistosoma mansoni
: A review of pathogenesis, clinical syndromes and diagnostic approaches. Rev Inst Med Trop Sao Paulo 2005;47:179-84.
Gryseels B, Polman K, Clerinx J, Kestens L. Human schistosomiasis. Lancet 2006;368:1106-18.
Wu L, Wu M, Tian D, Chen S, Liu B, Chen Q, et al
. Clinical and imaging characteristics of cerebral schistosomiasis. Cell Biochem Biophys 2012;62:289-95.
LlenasGarcía J, GuerraVales JM, AlcaláGaliano A, Domínguez C, PérezNuñez A, Lizasoaín M, et al
. Cerebral neuroschistosomiasis: A rare clinical presentation and review of the literature. BMJ Case Rep 2009;2009: bcr04.2009.1787.
Colley DG, Bustinduy AL, Secor WE, King CH. Human schistosomiasis. Lancet 2014;383:2253-64.
Tarabini-Castellani P, González-Chinchón G, Aldamiz-Echebarría M, Portu-Zapirain J, Apraiz-Garmendia L, Alvarez de Arcaya A. Neuroschistosomiasis: A challenging diagnosis. Rev Neurol 2007;44:154-6.
[Figure 1], [Figure 2]