The patient was a 24-year-old Hispanic male with unclear past medical history, possibly significant for seizures, who presented with emergency medical services (EMS) after a described five minutes of tonic-clonic seizure activity which was witnessed by family. Medics reported that the patient had told family about a fall at work the day prior. According to the family, the patient may have had seizures in the past but was not on medication. The seizure resolved prior to EMS arrival, and on initial EMS presentation the patient was confused, oriented only to himself, and only intermittently followed commands.
On arrival to the ED, the patient was alert and oriented to person, place, time, and answering questions, but was unclear on the events leading up to presentation. He stated that he fell at work and hit his head without loss of consciousness, and that he had been drinking beer the night prior. He denied any history of seizures and endorsed weekly alcohol use, but no history of withdrawal. His only complaint was of pain in his forehead and generalized weakness. Vital signs were significant for a temperature of 100.3  F, heart rate of 113, respiratory rate of 20, blood pressure of 135/96, and oxygen saturation of 100% on 4 liters nasal cannula. On exam, he was a tired-appearing male in no acute distress, with well-healing abrasions to the chin and forehead. Pupils were equal and reactive with bilateral conjunctival injection on eye exam. Neurological exam was notable for intact strength and sensation with no focal neurological deficits. He was alert and oriented and followed commands. A laceration was noted on the side of the tongue. Lab work was obtained, and the patient was sent for CT of the head and cervical spine.
Upon return from CT, the patient had a witnessed seizure lasting one minute which terminated with administration of lorazepam. After the seizure, the patient was extremely agitated, bucking in the stretcher and pulling at his intravenous (IV) access, followed by a period of somnolence with gurgling respirations. He was intubated for airway protection and sedated with propofol.
On review of his CT scan following intubation, several small, peripherally calcified lesions were noted by the EM clinicians per radiology; these findings were most consistent with cystic infection of the brain, likely neurocysticercosis.
In our patient, two lesions were most notable on CT in the frontal and occipital lobes. The lesion in the left frontal lobe (blue circle) was an approximately 1.5 centimeter (cm) rounded area with rim enhancement and surrounding hypodensity, consistent with vasogenic edema. A similar sized low-density area in the left occipital lobe (red circle) was noted, with increased peripheral density at the 3 o'clock position representing calcification. There were no areas of apparent hemorrhage or midline shift. The final radiology report concluded there were multiple cystic lesions, one with surrounding vasogenic edema in the left frontal lobe.
The patient was admitted to the intensive care unit under the care of neurology and infectious disease and treated with 10 milligrams (mg) IV dexamethasone and 4 grams (g) levetiracetam. He was extubated the following day. Twenty-four-hour video electroencephalogram (EEG) demonstrated no additional seizure activity. After he was extubated, the patient provided additional history that he had emigrated from Central America 5 years ago, and that he also had been hospitalized at a different facility for seizures 7 months ago. Records reviewed by the inpatient team revealed a previous diagnosis of neurocysticercosis for which the patient was treated with albendazole, but that he never picked up his outpatient prescription upon discharge. Polymerase chain reaction (PCR) testing was obtained (in lieu of enzyme linked blotting due to its availability), screening for tuberculosis (TB), strongyloides and human immunodeficiency virus (HIV) were negative, and an MRI redemonstrated three cystic lesions with ring enhancement. Infectious disease concluded the patient was likely in the degenerative phase of his disease and recommended treatment with albendazole and praziquantel. The patient continued to improve throughout his hospitalization and was discharged in good condition on levetiracetam to be taken for two years and a ten day steroid taper.