A 51-year-old male patient, who lives in a rural area, was first taken to the emergency department of another hospital with a 3-month history of headaches associated with gait alterations due to weakness of the lower limbs, instability, difficulty to climb stairs without support, memory loss and behavioral changes. The initial computed tomography (CT) of the head, according to his medical record and the radiology report, did not reveal any evident lesion and a lumbar puncture was performed showing hyperproteinorrachia, hypoglycorrhachia and mild lymphocytic pleocytosis. However, fungal and bacterial cultures, cryptococcus latex agglutination test, Mycobacterium tuberculosis (MT) polymerase chain reaction and MT culture were negative. Due to the lymphocytic pleocytosis and the high prevalence of tuberculosis in our country, empiric anti-tuberculosis treatment was started.
Nevertheless, the patient was evaluated again three months after his initial visit due to the persistence of symptoms and the onset of urinary incontinence, drowsiness, emesis and fever. The physical examination revealed that the patient was disoriented in time and space and had short-term memory difficulties. Acalculia was noticed. The examination of the eye fundus revealed bilateral papilledema without any other pathological finding. Physical examination did not reveal tremors or asymmetric pronation of hands. Rapid alternating movements and finger-to-nose movements were normal. However, the pull test was positive, and an ataxic gait was noticed. Meningeal signs were absent. Blood tests were carried out showing leukocytosis and neutrophilia without eosinophilia and a new lumbar puncture was performed with similar results to the previous, once again, all the infectious diseases investigations were negative. Due to the lack of response to the initial treatment, the diagnosis of meningeal tuberculosis was ruled out and treatment was suspended. Serological tests for Histoplasma, Cryptococcus and Aspergillus were negative.
A head CT scan revealed ventricular dilation and the presence of a cerebellar cyst (Figure 1); the magnetic resonance imaging (MRI) of the brain showed a left cerebellar cyst along with severe dilation of the ventricular system compatible with hydrocephalus (Figure 2), so that a ventriculoperitoneal shunt was performed. Due to the clinical deterioration of the patient and the lack of a clear diagnosis, a biopsy of the cyst was performed with evidence of a cysticercus cyst (Figure 3). Racemose neurocysticercosis with cerebellar involvement was considered and 8 mg of intravenous dexamethasone every 8 h in conjunction with albendazole at the maximum dose (30 mg/kg/day/) was started, as Praziquantel is not commercially available in Colombia. While hospitalized, the patient evolved with a progressive improvement of symptoms with subsequent discharge from the hospital. However, the follow-up visits were scheduled in another institution, and the patient was lost to follow up.