a previously healthy teenage girl , who had immigrated to oregon from mexico as an infant , sought care in january 2000 for progressively severe headaches of several months duration .
autopsy showed no evidence of trauma , and results of a toxicology screening were negative .
examination of the brain showed obstructive hydrocephalus , bilateral uncal herniation , flattening of the cerebral gyri , and an intact cysticercus compressing the inferior 4th ventricle ( figure 1 ) .
a ) coronal section of brain showing dilation of ventricles , flattening of the cerebral gyri , and uncal herniation .
we searched the oregon hospital discharge database to identify oregon hospitals that had discharged patients with the icd-9-cm code for neurocysticercosis ( 123.1 ) from january 1995 through december 2000 and requested the medical records of these patients .
we searched the oregon death certificate database for additional neurocysticercosis deaths during the same period .
a case of neurocysticercosis was defined as any person with a hospital discharge code of 123.1 or death certificate diagnosis of neurocysticercosis during the study period , and a record of imaging studies or pathology reports consistent with neurocysticercosis .
an incident case was defined as one for which no reference to any previous diagnosis of neurocysticercosis was found in the medical record .
incidence rates were calculated by using u.s . census bureau yearly population estimates for oregon as the denominator ( 2,3 ) .
data were analyzed with epiinfo , version 6.04d ( centers for disease control and prevention , atlanta , ga ) .
we found 89 hospital discharges coded for neurocysticercosis during the study period among 18 hospitals in 10 counties .
review of these records confirmed the diagnosis of neurocysticercosis for 59 persons ( 17 were admitted more than once ) .
thus , including the death described above , we found 61 persons who met the case definition for neurocysticercosis ; 43 ( 70% ) of these were incident cases .
the mean annual incidence rate from 1995 to 2000 was 0.2 per 100,000 general population and 3.1 per 100,000 hispanic population .
number of neurocysticercosis hospital discharges and new diagnoses by year ; oregon , january 1995december 2000 . among the 61 confirmed patients ,
40 ( 66% ) were male , and 52 ( 85% ) were hispanic . the median age at the time of first hospitalization was 24 years ( range 2 to 79 years ) ; 13 ( 21% ) were < 18 years old .
agriculture or other manual labor was the most common job type listed ( 20/37 ; 54% ) ; 21% patients were unemployed or disabled ; 40% of patients had no health insurance .
41 ( 72% ) were born in mexico , 10 ( 18% ) in the united states , 3 ( 5% ) in guatemala , and 1 ( 2% ) each in korea , saudi arabia , and an unspecified african country . of the 10 neurocysticercosis patients born in the united states ,
four of these five cases occurred among children ( ages 3 , 5 , 5 , and 12 years ) ; their source of exposure to taenia eggs was not documented .
the source of exposure for the adult patient was presumed to be a household contact visiting from mexico .
travel histories of four of the remaining u.s .- born patients included a caribbean cruise by a retired pig farmer , extensive travel in madagascar and tanzania by a student , annual visits to puerto rico by an 11-year - old , and 1 week spent in mexico city by a toddler .
no information about travel was documented for one patient , a 3-year - old child .
treatment included craniotomy with cyst removal ( 16%),ventriculoperitoneal shunting ( 12% ) , albendazole ( 18% ) , praziquantel ( 19% ) , anticonvulsive therapy ( 63% ) , and corticosteroids ( 49% ) .
two of these deaths also occurred unexpectedly before diagnosis ; both resulted from acute hydrocephalus caused by an obstructing cyst on the 4th ventricle .
the causes of death in these patients were aspiration pneumonia after craniotomy and cyst removal , intracerebral hemorrhage , and hydrocephalus due to recurrent cerebrospinal fluid shunt failure .
the median age at time of death was 33 years ( range 1773 years ) .
this study demonstrates that neurocysticercosis causes substantial illness and death among hispanic populations in oregon .
many of those affected are young immigrants from mexico without medical insurance , who are either unemployed or are working in agriculture or other manual labor .
our study did not address where disease transmission occurred for persons born outside of the united states ; some of these cases could also have been acquired locally .
several previous reports have documented the increasing recognition of neurocysticercosis in the united states , but the emphasis has been primarily on disease occurring in southwestern states bordering mexico ( 4 ) and small outbreaks elsewhere ( 57 ) .
previously , the only available information about the occurrence of neurocysticercosis in the pacific northwest was a study of seizure patients at 11 university - affiliated , urban emergency departments throughout the united states . in that study
, cases were concentrated in southwestern states ; four cases were found in oregon during a 2-year period ( 8) . the study underestimated the incidence of this disease in the northwest , and perhaps other areas of the united states , by looking for cases only in selected urban emergency departments .
the average annual incidence of neurocysticercosis among oregon s hispanic population found in our study is higher than that previously reported in los angeles county ( 1.6/100,000 ) ( 9 ) and in mexico ( 0.8/100,000 ) ( 10 ) .
census bureau population estimates due to undercounting of hispanic migrants could have resulted in a falsely elevated incidence rate .
in addition , the higher observed incidence in oregon may have been a result of greater case ascertainment because hospital discharge data were used rather than physician and laboratory reports .
nevertheless , because of our study design , we probably underestimated the true number of incident cases .
persons in outpatient clinics and emergency departments in whom neurocysticercosis had been diagnosed ( who did not become hospitalized ) were not counted in our study .
we also did not include in the analysis of cases 15% of hospital discharge diagnoses that we could not confirm by chart review ; if these had been confirmed as neurocysticercosis , then the true number of new cases may have been even higher .
although the hispanic population in oregon grew by an estimated 67% during the study period ( 2,3 ) , the number of hospitalizations and new diagnoses did not increase . whether this finding represents
a true decrease in incidence or a shift in diagnosis and management of these cases to the outpatient setting , is unclear .
neurocysticercosis has not previously been a reportable condition in oregon , and no public health followup of the patients with locally acquired cases was performed to determine the source of these persons exposures to taenia eggs .
previous serologic studies ( 11,12 ) would suggest that these patients acquired disease from household contact with a t. solium carrier .
early identification and public health followup of neurocysticercosis patients may lead to the recognition and treatment of tapeworm carriers , thereby preventing additional cases .
however , since excretion of taenia eggs is intermittent , direct parasitologic examination of stools is not a sensitive test ( 11 ) .
a serologic test for detection of taenaisis has been developed ( 13 ) , but it is not yet commercially available .
public health providers need simple , inexpensive , and readily available techniques for rapidly identifying taenia carriers in order to conduct optimal followup of cases and prevent additional cases .
the world health organization has estimated that more than 2 million persons are infected with adult tapeworms ( 14 ) .
as a result of increasing immigration and foreign travel , t. solium will likely continue to emerge as an important pathogen in the united states .
we recommend that public health surveillance activities more accurately define the incidence and risk factors for illness in oregon , allow identification and treatment of tapeworm carriers , and provide epidemiologic and clinical data to physicians caring for patients in at - risk populations .
 the unexpected death of a teenager from neurocysticercosis prompted an investigation of this disease in oregon . 
 we found 89 hospitalizations , 43 newly diagnosed cases , and 6 deaths from 1995 to 2000 . 
 at least five cases occurred in persons who had not traveled or lived outside the united states . 
 enhanced surveillance for neurocysticercosis is warranted . 
Case Report
The Study
Conclusions