Ashdin Publishing Journal of Neuroinfectious Diseases Vol. 4 (2013), Article ID 235712, 2 pages doi:10.4303/jnd/235712 ASHDIN publishing Case Report Natural History of Multiple Giant Cysts in Neurocysticercosis M. Puccioni-Sohler, 1,2 D. A. Benevenuto, 1 R. H. S. Peralta, 3 and J. M. Peralta 3 1 Escola de Medicina e Cirurgia, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil 2 CSF Laboratory, Clinical Pathology Service, Hospital Universit´ ario Clementino Fraga Filho/Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil 3 Microbiology Institute, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil Address correspondence to M. Puccioni-Sohler, mpuccioni@hucff.ufrj.br Received 4 March 2013; Accepted 16 April 2013 Copyright © 2013 M. Puccioni-Sohler et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Teniasis and cysticercosis represent a considerable public health issue and have been estimated to affect more than 50 million people worldwide per year. Neurocysticercosis is the most common parasitic infection of the central nervous system and acquired epilepsy is a frequent manifestation of the disease in developing countries. The growth of cysticercus more than 50 mm in diameter is called giant cysts, and they are considered an expansive lesion. Some of them can induce mass effect and development of hydrocephalus and intracranial hypertension. We report a case of neurocysticercosis, characterized by extensive and multiple giant cysts, which coped with balanced intracra- nial hypertension. Keywords neurocysticercosis; epilepsy; headache; intracranial hyper- tension; giant cysts; subarachnoid cysts 1. Introduction Neurocysticercosis (NCC) is caused by Taenia solium infec- tion in the central nervous system (CNS) [3, 6]. NCC rep- resents an important cause of acquired epilepsy in devel- oping countries. Seizures, headache, psychiatric symptoms, intracranial hypertension, and cysticercotic meningitis are common manifestations [7]. Giant cysts (more than 5 cm in diameter) are not frequent in NCC, occurring in approxi- mately 10% of cases [5]. We present a patient from a non-endemic area who had extensive neurocysticercosis characterized by giant cysts, with apparent compensation of intracranial hypertension. 2. Case report A 47-year-old Brazilian black man from Rio de Janeiro, Brazil, was admitted to our hospital in 2008. The patient reported a strong, daily holocranial headache that were relieved by analgesics and exacerbated by anxiety. He had history from 1989 to 2004 of generalized tonic-clonic seizures associated with sialorrhea and disturbance of consciousness that were preceded by scintillating scotoma and paresthesiae in the left upper limb. The patient had childhood contact with pigs. The neurological examination and funduscopy were normal. A serum Western blot for Taenia solium and Taenia crassiceps were both positive. A cerebrospinal fluid (CSF) analysis was performed 2 months before admission to our hospital and revealed pleocytosis (21 cells/mm 3 , 92% lymphocytes), hyperproteinorrachia (66 mg/dL) and reactive hemagglutination, immunofluo- rescence, and ELISA tests for NCC. The EEG exhibited diffuse slow waves. Soft tissue (thigh) simple radiography demonstrated calcifications compatible with cysticercosis. A brain CT/MRI scan exposed multiple infratentorial, supratentorial, and subarachnoid ring-like enhancing and nodular lesions. Some of these were calcified, and others appeared with scolex (Figure 1). Additionally, the patient’s condition escalated with anxiety, depressive symptoms, insomnia, and daily episodes of sweating that lasted a few seconds. Chlordiazepoxide and amitriptyline were successfully prescribed. 3. Discussion We report a case characterized by contact with pigs dur- ing childhood, suggestive clinical manifestations of NCC, a positive serum Western blot for T. solium, and a reactive ELISA test of CSF [3]. The CT and MR imaging showed multiple large, bilateral cystic lesions, with scolex. Some of these lesions caused midline shift, representing a tumoral form of NCC [5]. In accordance with other reports of NCC, seizures were the first manifestations of the disease, proba- ble associated with intraparechymal lesions. However, mass effect became apparent only some years later, due to the late development and growth of intraparenchymal and extra- parenchymal (Sylvian fissure) cysticercosis. We hypothesize that there was a compensation of the intracranial pressure due to the presence of the bilateral lesions and the slow growth of the cysts, contributing to the control of the ini- tial intracranial hypertension [4]. Otherwise, the detection of