Cerebral schistosomiasis presenting as a brain tumor

Surgical management outcome of cerebral schistosomiasis: a case report and review of the literature

BACKGROUND

Schistosomiasis is a parasitic infection that commonly affects the gastrointestinal and genitourinary tracts. Cerebral schistosomiasis is rare, and few operative cases have been reported in the literature. Diagnosis is usually challenging due to the similarity of the lesion to many other brain conditions. Treatment usually requires surgical resection combined with the use of antiparasitic agents, which often results in good outcomes and excellent prognosis.

CASE PRESENTATION

A 24-year-old, previously healthy Afro-asiatic man presented to our neurosurgical outpatient clinic complaining of headache and an attack of convulsions. On examination, he had bilateral lower limb weakness more on the right side. Laboratory investigations including stool and urine general test results were unremarkable. Magnetic resonance imaging of the brain was performed and showed an intra-axial left parietal mass; a granulomatous lesion was suggested in the differential diagnoses. The patient underwent craniotomy and total resection of the lesion. Histopathology confirmed the presence of active cerebral Schistosoma mansoni infection. Orally administered praziquantel was initiated at a dose of 20 mg/kg twice a day for a total of 3 days along with oral administration of corticosteroids for 2 weeks. The patient improved postoperatively without residual weakness and with no further convulsions.

CONCLUSION

Cerebral schistosomiasis is a rare but important consideration in the list of differential diagnoses of cerebral space-occupying lesions. This is of particular importance in in endemic areas like Sudan. In order to reach a diagnosis, careful social and occupational history need to be obtained and correlated with the clinical, laboratory, and radiological findings. Surgical resection along with the use of proper antiparasitic agents usually provides the best clinical outcomes.

Delayed presentation of cerebral schistosomiasis presenting as a tumor-like brain lesion

Schistosomiasis is the second most common parasitic infection worldwide. North America is a nonendemic area. However, there are occasional case reports among travelers and immigrants from endemic regions. We describe a case of a 55-year-old Canadian woman who presented with first episode of seizure. Her magnetic resonance imaging scan revealed a mass-like lesion involving the left anterior temporal lobe. The lesion showed T1 hypo- and T2 hyperintense with perilesional brain edema. On post-gadolinium-enhanced T1-weighted sequence, the lesion showed multiple small nodular and linear enhancements, also called an "arborized" appearance. Initially, the lesion was thought to be a malignant tumor. She underwent left anterior temporal lobe resection. Histologic examination showed parasitic eggs with a characteristic lateral spine consistent with Schistosoma mansoni infection. Upon subsequent questioning, it was revealed that the patient lived in Ghana from the ages of 8-10 years and she visited Ghana again 10 years prior for two weeks. She recalled swimming in beaches and rivers. Latent disease, as in this case with presentation, many years or decades after presumed exposure is rare but has been reported. Characteristic magnetic resonance imaging findings may suggest the diagnosis and facilitate noninvasive work-up.

Pseudotumoral form of cerebral Schistosomiasis Mansoni

The authors report a case of 36-year-old woman presented with epileptic seizures and headaches. Magnetic resonance imaging (MRI) revealed an enhancing lesion with surrounding edema and mild mass effect in the left frontal lobe. Stereotactic brain biopsy demonstrated intraparenchymal granulomas surrounding S. mansoni eggs. Praziquantel was started (60mg/kg of body weight, in a single dose), followed by Prednisone (80mg/day) for seven days to treat the cerebral edema. The patient’s symptoms resolved following medical treatment and the follow-up MRI yielded normal findings.

Schistosomiasis mansoni presenting as a cerebellar tumor: case report

The Manson's schistosomiasis tumoral form rarely affects the brain. There are only 12 cases prior related with a mean age of 25 years and a male predominance. We describe a 16-year-old Brazilian Northeastern boy with a cerebellar mass lesion. The radiological aspect was considered compatible with glioma and a gross total resection was performed. Microscopic examination disclosed intraparenchymal granulomas surrounding Schistosoma mansoni eggs. The case is compared with the literature findings and some peculiar aspects of this trematode infection are reviewed.

Neuroparasitic infections: cestodes, trematodes, and protozoans

Parasitic infection of the nervous system can produce a variety of symptoms and signs. Because symptoms of infection are often mild or nonspecific, diagnosis can be difficult. Familiarity with basic epidemiological characteristics and distinguishing radiographic findings can increase the likelihood of detection and proper treatment of parasitic infection of the nervous system. This article discusses the clinical presentation, diagnosis, and treatment for some of the more common infections of the nervous system caused by cestodes, trematodes and protozoans: Echinococcus spp., Spirometra spp. (sparganosis), Paragonimus spp., Schistosoma spp., Trypanosoma spp., Naegleria fowlerii, Acanthamoeba histolytica, and Balamuthia mandrillaris.

Manson's schistosomiasis presenting as a brain tumor. Case report

Neurological complications arising from schistosomiasis are uncommon, and reports of Manson's schistosomiasis presenting as an intracerebral mass lesion are particularly rare. The authors describe the case of a 26-year-old man with a 3-month history of headaches and visual abnormalities. He had immigrated to Canada from Brazil 4 years previously. The patient's general physical and neurological examinations were unremarkable. Magnetic resonance (MR) imaging revealed an enhancing lesion with surrounding edema and mild mass effect in the right occipital lobe. A stereotactic brain biopsy demonstrated intraparenchymal granulomas surrounding Schistosoma masoni eggs. The patient's symptoms resolved following treatment with praziquantel and steroid medications; follow-up MR imaging yielded normal findings. This case demonstrates that neuroschistosomiasis should be considered when an individual presenting with an intracerebral mass has lived in a region in which this disease is endemic.

[Tumor form of encephalic schistosomiasis: presentation of a case surgically treated]

The involvement of the central nervous system in the Schistosomiasis mansoni is uncommon and in the literature exist few reports in relation this occurrence in the brain, in that the schistosoma eggs, usually promote a granulomatous reaction that remember an expansive tumour. A patient, male sex, from São Vicente de Ferrer (MA), 27 years old, had a tumour in the cerebellum, that had surgical therapy. Later histological studies of the cerebellar material of the patient, demonstrated an extensive granulomatous reaction around schistosoma eggs. The granulomatous reaction present different stages of evolution, since degenerative necrosis to organization granulomatous reaction. This is the first report from Maranhão (Brazil). The evolution of the patient was characterized for incoordination of members and trembling.

Neuroschistosomiasis

Schistosomiasis is an infection caused by digenetic trematode platyhelminths of the genus Schistosoma. These blood flukes use man and other mammals as definitive hosts and aquatic and amphibious snails as intermediate hosts. Of the schistosomal species, S. mansoni, S haematobium and S. japonicum are the most important to man and the most widely distributed. The infection affects about 200 million individuals in 74 countries of Latin America, Africa and Asia. Far less commonly, schistosomes reach the central nervous system (CNS). This may occur at any time from the moment the worms have matured and the eggs have been laid. For this reason, CNS involvement may be observed with any of the clinical forms of schistosomal infection. The presence of eggs in the CNS induces a cell-mediated periovular granulomatous reaction. When eggs reach the CNS during the early stages of the infection or during evolution of the disease to its chronic forms, large necrotic-exudative granulomas are found. In-situ egg deposition following the anomalous migration of adult worms appears to be the main, if not the only, mechanism by which Schistosoma may reach the CNS in these stages. The mass effect produced by the heavy concentration of eggs and the presence of large granulomas in circumscribed areas of the brain and spinal cord explains, respectively, 1) the signs and symptoms of increased intracranial pressure and focal neurological signs; and 2) the signs and symptoms of rapidly progressing transverse myelitis, usually affecting the lumbosacral segments of the spinal cord. Most of the cases of CNS involvement associated with the hepatosplenic and cardiopulmonary chronic forms, or with severe urinary schistosomiasis, though more frequent, are asymptomatic. In the patients with these clinical forms, the random and sparse distribution of eggs in the CNS indicates that the embolization of eggs from the portal mesenteric system to the brain and spinal cord constitutes the main route of CNS invasion by Schistosoma. The discrete inflammatory reaction elicited by the sparsely distributed eggs in the CNS explains the lack of neurological symptoms that could be produced by egg deposition.

Tumoral form of cerebral schistosomiasis mansoni. A report of four cases and a review of the literature

We describe four cases of the tumoral form of cerebral schistosomiasis mansoni. The patients had symptoms of increased intracranial pressure and focal neurological signs that varied according to the site of the lesion. Computerized tomography showed a hyperdense, enhancing lesion located in the cerebellum (2 patients), frontal lobe and thalamus (1 patient), and temporal subdural region (1 patient), with associated mass effects. The lesion was resected in three patients and a stereotactic biopsy was performed in one. Histopathologic specimens of all four patients revealed multiple schistosomal granulomas in various evolutive phases. Two of these patients differ from previously described cases; one because of the subdural location of the lesion, mimicking a meningioma, and the other one because two lesions were present.

Parasitic infections of the central nervous system in children. Part III: Space-occupying lesions

In the last part of this three-part review of parasitic infections of the central nervous system in children, we consider parasites which due to their size, distribution, or the nature of the host response, tend to cause focal lesions in the brain and spinal cord and therefore present as space-occupying lesions which occasionally mimic malignant tumors. As in Parts I and II, infections are grouped according to their predominant geographic area. Such infections include cysticercosis, one of the more common and important infections of the central nervous system.

Cross reactions in the immunodiagnosis of schistosomiasis and cysticercosis by a cerebrospinal fluid enzyme-linked immunosorbent assay

Cerebrospinal fluid was collected from 3 groups of patients (suspected cysticercosis patients, myelopathy patients, and neurological patients) and assayed for antibodies to Cysticercus cellulosae and schistosome soluble egg antigen. In the myelopathy and neurological patients there was a significant correlation (P less than 0.05) between seropositivity for the two diseases. Samples which were positive in both assays were tested by inhibition assay with the heterologous antigen to determine the specificity of the reaction. In one of 5 cases the reaction to cysticercus antigen was completely inhibited by addition of schistosome soluble egg antigen. In the reverse assay there was minimal inhibition by cysticercus antigen.

Tumoural form of cerebellar Schistosomiasis mansoni. Report of a surgically treated case

A case of the tumoural form of cerebellar Schistosomiasis mansoni is described. The patient was a 35-year-old female, healthy until one year ago, when she started to show cerebellar and vestibular symptoms. Computerized tomography was performed and showed an expanding lesion in the cerebellar vermis and roof of the fourth ventricle, which was surgically removed. On histopathological examination numerous S. mansoni ova involved in chronic granulomatous inflammation were found. Innumerable granulomas in the productive and healing phases of fibrosis as well as rare ones in the necrotic-exudative phase were observed. This case is compared with another three previously reported in the literature. The clinical picture, diagnostic methods, the relation to the other forms of visceral involvement in Schistosomiasis mansoni and how the parasite reaches the brain are commented upon.