Transactions of the Royal Society of Tropical Medicine and Hygiene (2006) 100, 134—141

Pleomorphism of the clinical manifestations
of neurocysticercosis
R. Patel, Sanjeev Jha ∗, R.K. Yadav
Neurology Department, Sanjay Gandhi PGIMS, Lucknow, India
Received 15 July 2004 ; received in revised form 23 June 2005; accepted 23 June 2005
Available online 7 October 2005
KEYWORDS
Neurocysticercosis;
Kluver—Bucy syndrome;
Weber’s syndrome;
Dementia;
Cortical blindness;
India

Summary Neurocysticercosis (NCC) remains a major public health problem in
developing countries as it is the most common helminthic infection of the central nervous system. Clinical manifestations are non-specific and pleomorphic. Case
reports on uncommon presentations of NCC are few. We report six interesting cases
of NCC with unusual clinical presentation that demonstrate this spectrum of pleomorphism. These include extrapyramidal disease (parkinsonism and focal dystonia),
Kluver—Bucy syndrome, Weber’s syndrome, dementia and cortical blindness. The
clinical details and possible mechanisms for the uncommon presentations are also
discussed. Thus, a high level of suspicion should be kept for NCC, especially in
endemic zones and developing countries.
© 2005 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and
Hygiene.

1. Introduction
Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system. The
incidence of NCC is increasing in non-endemic areas
of the world, including India, owing to immigration
from endemic areas (Sawhney et al., 1998; Singhi
and Singhi, 2004). NCC occurs when ingested ova
develop into larvae (cysticerci) and lodge in soft
tissues, especially skin, muscle and brain. The cyst
may be located anywhere in the brain, and clinical features depend on its location (Del Brutto et
al., 1992; Sawhney et al., 1998). Clinical manifestations are pleomorphic, depending on the number,
∗ Corresponding author.

E-mail address: sjha@sgpgi.ac.in (S. Jha).

size and topography of lesions and on the severity of the host immune response to the parasite,
which varies according to the stage of cysticercosis
(Del Brutto et al., 1992; Singhi and Singhi, 2004).
Cysticerci are fluid-filled oval cysts, approximately
1—2 cm in diameter, with an internal scolex. There
are four stages in the development of NCC: vesicular, colloidal, granular and calcified. Each stage is
characterised by specific changes within the parasite and in the surrounding brain parenchyma,
with a distinctive appearance on neuroimaging. In
the vesicular stage, the vesicular wall of the parasite is translucent and fluid is transparent with
viable invaginated scolex. The brain parenchyma
shows a scarce inflammatory reaction. Neuroimaging reveals hypodense cystic lesions showing the
scolex; following contrast medium administration

0035-9203/$ — see front matter © 2005 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene.
doi:10.1016/j.trstmh.2005.06.028

Pleomorphism of neurocysticercosis
there is no abnormal enhancement. In the colloidal
stage, the vesicular wall is thick with viscous, turbid
fluid and a scolex showing signs of hyaline degeneration. The brain parenchyma shows an intense
inflammatory reaction and a thick capsule is formed
around the parasite. The lesion is isodense or hypodense, surrounded by oedema and ring-like or nodular enhancement on contrast-enhanced imaging.
In the granular stage, there is a thick vesicular
wall with a degenerated scolex, astrocytic gliosis
around the cyst, and a hyperintense nodule that
enhances following contrast medium administration. The calcified stage involves transformation of
the parasite into a small, mineralised nodule. The
brain parenchyma shows intense gliosis. Imaging
reveals a small calcification (Del Brutto and Sutelo,
1988).
Seizures are the commonest clinical features.
In addition, other clinical features include raised
intracranial pressure, syndromes of cerebellopontine angle lesion, dementia and stroke (pure motor
hemiparesis, ataxic hemiparesis, etc.) (Pal et al.,
2000; Wallin and Kurtzke, 2004). Perinaud syndrome
and Brown—Sequard syndrome have also been documented with NCC (Del Brutto, 1997; Liu et al.,
1992). It is important to be aware of these rare
and diverse presentations, since they mimic a large
number of neurological disorders. Lack of awareness may result in erroneous diagnosis, especially in
tropical countries (Sawhney et al., 1998). Here we
report a few cases of NCC presenting with clinical
manifestations of extrapyramidal disease (parkinsonism and focal dystonia), Kluver—Bucy syndrome, Weber’s syndrome, dementia and cortical
blindness.

2. Patients
We report six interesting cases of NCC with unusual
clinical manifestations who were referred over the
last 4 years (2001—2004) to the Department of Neurology, Sanjay Gandhi PGI, Lucknow, which is a tertiary care centre in northern India. The diagnosis of
NCC was made on the basis of clinical and radiological features (Del Brutto et al., 2001).

2.1. Case 1
A 60-year-old farmer presented with complaints
of tremors and difficulty in walking approximately
a year prior to reporting. Tremors started from
the left upper limb and then gradually progressed
to involve the right upper limb over a period of
3 months. The tremors of both types (resting and
action) were aggravated by movement (especially

135
on picking up any object) and emotional stress.
He was also having difficulty in walking, resulting
in abnormal gait and unstable posture. There
was no history of hypertension, diabetes, alcoholism, seizures, motor weakness, bladder/bowel
involvement or decline in cognition. In addition, there was no history of familial movement
disorder.
Examination revealed characteristic parkinsonian features with a staring, mask-like face. The
blink rate was grossly diminished. He had dysarthria
of speech, which was scanning, hypophonic and
monotonous. Mental activity (Mini Mental State
Examination (MMSE)) was normal. There was dystonic posturing of the feet, with the great toe
held in a state of sustained dorsiflexion (striatal
toe). Resting tremors were present in both hands,
which were exacerbated by action. Posture was
stooped (Figure 1a) and unstable, and his gait
was short, shuffling and festinating. Ocular movements were full. Saccadic movements of the eye
were slow, whilst pursuit movements were broken.
Power, deep tendon reflexes and plantar response
were normal, but cogwheel rigidity was present in
all four limbs. Sensory examination did not reveal
any abnormality. There were no cerebellar signs or
dysautonomia. Other systemic examinations were
normal.
Cranial magnetic resonance imaging (MRI)
revealed multiple cysticerci in various stages
(vesicular and granular). Few of them were cystic
with a scolex. They were scattered bilaterally
throughout both cerebral hemispheres including
the basal ganglion (Figure 1b). ELISA for cysticerci
in the cerebrospinal fluid (CSF) was positive,
whilst proteins (38 mg%), sugar (60 mg%) and cells
(2 lymphocytes/mm3 ) were normal. Haematology,
urinalysis, serum chemistry, chest radiography
and electroencephalography (EEG) were normal.
The patient was managed conservatively with
levodopa (110 mg thrice daily) and trihexyphenidyl
(2 mg thrice daily). He reported initially with
improvement in tremors, rigidity and dystonia but
was later lost to follow-up.

2.2. Case 2
A 19-year-old female presented with sustained
abnormal posturing of the left upper limb approximately 2 years prior to reporting. Onset was acute,
first involving the left thumb and then progressing over 2—3 days to involve the whole of the
left hand. The abnormal posture was sustained
without any fluctuation. She was able to partially correct her abnormality voluntarily. There
was no history of seizures, unconsciousness, fever,

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R. Patel et al.

Figure 1 (a) Photograph of Case 1, showing the stooped posture and parkinsonian features. (b) Cranial MRI of the
same case, demonstrating the multiple neurocysticercosis cysts.

jaundice, exposure to toxins or consumption of
drugs. There was no history of familial movement
disorder.
Examination revealed sustained dystonia involving all fingers of the left hand, predominantly the
thumb, in attitude of flexion. Other limbs were
normal. Her mental functions, speech and cranial
nerves were normal. Muscle tone, power and deep
tendon reflexes, including plantar response, were
normal. There was no craniovertebral abnormality
and sensory examination was normal. There were
no cerebellar or autonomic dysfunctions.
Her haematology, serum chemistry and chest
radiography were normal. Mantoux test was negative. Blood ELISA for cysticerci was positive.
CSF examination and EEG were normal. Slit lamp
examination did not reveal any Kayser—Fleischer
(KF) ring. Cranial computerized tomography (CT)
revealed a single, ring-enhancing granuloma in the
right thalamic region (colloidal stage) (Figure 2).
She was managed with albendazole (15 mg/kg
body weight) daily for 3 weeks. Steroids
(0.75 mg/kg/day) were given to prevent any
adverse effect. She did not show any improvement
and was later lost to follow-up after 6 months.

Figure 2 Cranial scan showing a single ring-enhancing
lesion in the right thalamic region.

Pleomorphism of neurocysticercosis

Figure 3 Cranial scan showing multiple, small, calcified
lesions, scattered bilaterally in the parenchyma.

2.3. Case 3
A young girl, aged 12 years, developed focal
seizures and Todd’s palsy approximately 6 months
prior to reporting. No EEG or cranial imaging was
done at that time. The seizures were controlled on
carbamazepine, prescribed by her family physician.
She presented with acute severe headache, vomiting and abnormal behaviour in the form of explosive
temper, hyperorality and increased sexual instincts
(stroking sex organs). On being scolded, she
immediately became placid. Examination revealed
bilateral papilloedema. Other cranial nerves were
normal and there was no motor or sensory deficit.
Haematology, clinical chemistry (hepatic and renal
profile) and chest radiography were normal. EEG
was abnormal, with intermittent epileptiform discharges. Cranial CT revealed multiple granulomas
scattered bilaterally in the cerebral hemispheres
in colloidal and granular stages. Few of them had
an eccentric scolex, suggestive of NCC (Figure 3).
There was significant improvement in headache
and vomiting with intravenous mannitol and oral
glycerine. There was gradual improvement in
behaviour, with decreased frequency of outbursts,
hyperorality and sexual overtones. She remains
seizure free and has normal behaviour on regular
follow-up.

2.4. Case 4
A 45-year-old male presented with sudden diplopia
and hemiparesis of the right side, followed by ptosis
on the left eyelid, which progressed over 5—6 h. He

137

Figure 4 Cranial MRI (T2 axial section), showing cystic
lesion with scolex in the left midbrain region with marked
perilesional oedema.

was managed initially by the family physician with
steroids and albendazole, with which he improved
gradually over 1 week. He remained asymptomatic
for approximately 20 d, when he again developed
diplopia, hemiparesis of the right side, along with
ptosis with ophthalmoparesis in the left eye. There
was no history of hypertension, diabetes, alcoholism, headache, vomiting, fever, unconsciousness, seizure or behavioural abnormalities.
Examination revealed normal mental functions.
He had dysarthria in the form of scanning speech.
Cranial nerve examination revealed 3rd nerve palsy
(ptosis with ophthalmoplegia) on the left side and
facial palsy (upper motor neuron type) on the
right side. He had hemiparesis (power grade 3/5
in upper and lower limb) on the right side. Cranial MRI revealed multiple ring-enhancing lesions
with scolex (vesicular and colloidal stage of NCC) in
the left midbrain region with perilesional oedema
(Figure 4). The patient was treated by anti-oedema
measures on which he recovered completely.

2.5. Case 5
A 40-year-old male presented with progressive forgetfulness 1 month prior to reporting. He forgot
the names of close relatives and family members.
He also developed progressive inability to perform activities of daily living. He was taking carbamazepine prescribed by his family physician for
seizures (focal with secondary generalisation) for 2
years. There was no previous history of diabetes,

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R. Patel et al.

Figure 6 Cranial MRI showing multiple neurocysticercosis cysts located bilaterally in the occipital cortex.

The patient continues to report significant improvement in cognition.

2.6. Case 6

Figure 5 (a) T1 and (b) T2 axial cranial MRI section,
showing multiple ring-enhancing lesions, i.e. neurocysticercosis cysts in various stages, scattered throughout
the parenchyma including the brainstem.

hypertension, coronary artery disease, cerebrovascular accident, transient ischaemic attack, or exposure to drugs or toxins.
On examination he had dementia (MMSE score
17) and made gross errors in calculation. Cranial nerves, and motor and sensory examination
were normal. Other systemic examinations, including cardiac, were normal. MRI revealed multiple
ring-enhancing granulomas (all four stages of NCC)
bilaterally in the cerebral hemispheres and midbrain (Figure 5a and b). The patient was managed
with anti-oedema treatment and anti-epileptics.

An 11-year-old female child had seizures (partial
with secondary generalisation) that were well controlled with carbamazepine. She presented with
acute bilateral loss of vision, which she denied.
She also had severe holocranial headache associated with vomiting.
On examination, her visual acuity was reduced to
perception of light and hand movements only. Fundus examination revealed bilateral papilloedema.
Motor and sensory examination was normal. Routine
investigations including haematology, biochemistry and urine analysis were normal. Cranial MRI
revealed multiple cysticerci (colloidal and granular
stages) scattered throughout both cerebral hemispheres including the occipital cortex (Figure 6).
She was managed with anti-oedema measures
and anti-epileptics. On follow-up her vision had
improved significantly.

3. Discussion
Epilepsy is the commonest presentation of
parenchymal NCC, occurring in 50—80% of patients
(Carpio et al., 1998; Medina et al., 1990). Our
first patient presented with tremor, rigidity and
dystonia. The locations of lesions in the caudate,
palladium and thalamus were responsible for
parkinsonian features and dystonia, respectively,
in our patients. Potential mechanisms for this are
an inflammatory reaction that accompanies death
of the parasite, with oedema and dysfunction of
perilesional tissue or mass effect (Bhigjee et al.,
1987; Garcia et al., 2003). Unilateral dystonic

Pleomorphism of neurocysticercosis
posturing is an unusual feature of epilepsy that
has been reported in complex partial seizure of
temporal origin (Cardoso, 1998; Kongel et al.,
1989). In our patient, the dystonic posturing was
sustained and EEG was normal, which differentiated it from seizures. Focal cerebral lesion may
cause unilateral dystonia or hemidystonia due to
involvement of the putamen, thalamus and less
often the globus pallidus or caudate nucleus, which
can be diagnosed by imaging (Bhigjee et al., 1987).
The most common cause is cerebral infarction
in which dystonia evolves with the resolution of
hemiparesis after a variable delay of weeks or
months (Cantu and Barinagarrementeria, 1996;
Sawhney et al., 1998). Other focal brain lesions
such as tuberculoma, NCC or space-occupying
lesions are common causes of focal dystonia in
tropical countries (Garcia and Del Brutto, 2003;
Sawhney et al., 1998). The diagnosis may be missed
since patients may present with rare clinical features, more so in developing countries owing to
limitations of investigations.
The available data indicate that symptomatic
dystonia may be caused by isolated lesions in the
putamen, caudate, thalamus, globus pallidus or
their connecting pathways. Animal data show that
there is a gross somatotropic arrangement of input
to the putamen so that the leg area is anterodorsal, the face area is posteroinferior and the arm
area is in the middle (Cardoso, 1998; Kongel et al.,
1989). This topography of lesions roughly coincides
with the distribution of dystonia in our patients.
Our second patient presented with dystonia involving the left upper limb, which may possibly be due
to involvement of the thalamus as revealed on cranial MRI.
Involvement of the temporal lobes by hydrocephalus and perilesional oedema induced by NCC
may be probable explanations for the features of
Kluver—Bucy syndrome in our patient. Anatomical
analysis of Kluver—Bucy syndrome with other diseases is controversial, although an intimate association with temporal lobe damage has been widely
reported (Hart et al., 1986; Poeck, 1985). Isolated
damage to the amygdalae and their cortical connections following cancer treatment has been widely
confirmed by radioimaging and positron emission
tomography. It has been conjectured that this syndrome also results from disruption of pathways connecting dorsomedial thalami with the pre-frontal
cortex and other limbic areas that are essential for
memory and regulation of emotions (Biswas et al.,
1998a; Hayman et al., 1998; Muller et al.,
1999).
Localising studies (clinical and anatomical) indicate the involvement of the phylogenetically old

139
medial temporal lobe regions and bilateral lesions
of Ammon’s horn for presentation of this syndrome.
In addition, compression of hippocampi may also
occur (Olson, 2003).
A number of changes in sexual behaviour are
associated with temporal lobe epilepsy and its
treatment by lobectomy. As many as 71% of patients
with temporal lobe epilepsy exhibit altered sexual
behaviour associated with ictal events. Interictal
hyposexuality occurs in 80% of the patients; 20%
exhibit a variety of paraphilias. When these hyposexual patients have a unilateral temporal lobectomy, their libido frequently increases and becomes
excessive in some cases. Conversely, aberrant sexual behaviour as part of the ictal manifestation
of temporal lobe seizures is also well documented
(Greenwood et al., 1983).
Episodes of seizures may reflect transient bilateral dysfunction of the temporal lobe. Such temporary functional bilateral lobectomy could cause
the same syndrome as an anatomical lobectomy
and would be similar to the pathophysiological
mechanism that may account for our patient’s
abnormal behaviour. Carbamazepine and leuprolides have been found to decrease the sexual
behaviour in some individuals with Kluver—Bucy
syndrome. Other medications such as haloperidol and anticholinergics may also be useful in
treating behavioural abnormalities associated with
Kluver—Bucy syndrome (Hooshmand et al., 1974).
Our patient with Weber’s syndrome had NCC with
gross perilesional oedema located in the midbrain
region that was possibly responsible for ptosis and
ophthalmoparesis. The approximate incidence of
cerebral infarcts is 4—12% with NCC (Fleury et
al., 2004; Scharf, 1988). Various mechanisms are
involved in the genesis of stroke in patients with
NCC. It may be related to thrombosis of superficial cortical vessels owing to chronic meningitis.
It may be due to fusiform aneurysms produced by
weakening of the wall of the vessels or due to occlusion of small perforating vessels affected by endarteritis. Patients may present with lacunar infarct,
large artery infarction, progressive midbrain syndrome and recurrent transient ischaemic attacks.
The severity of cerebrovascular complication of
NCC is related to the distribution of cysticercal
disease and the severity of accompanying arachnoiditis. Hence, when cysts are confined to a focal
area and associated with mild arachnoiditis, they
involve small penetrating vessels manifesting as
lacunar syndrome. When the cysts are widespread
and accompanied by significant arachnoiditis, the
associated vasculitis involves the main vessels
of the circle of Willis with segmental narrowing
of major intracranial arteries that produce large

140
cerebral infarcts (Alarcon et al., 1992; Cantu and
Barinagarrementeria, 1996; Jha and Kumar, 2000).
The most common cause of Weber’s syndrome
is vascular due to occlusion of the peduncular and
interpeduncular branches of the posterior cerebral
artery, often owing to embolic occlusion (Koroshetz
and Ropper, 1987). We feel the diagnosis of NCC
should be included in the list of causes of stroke
in the young, particularly in endemic areas. It is
important to diagnose the cysticercotic angitis, as
these patients require immediate steroid therapy
to reduce subarachnoid inflammatory reaction that
may cause recurrent cerebral infarcts (Jha and
Kumar, 2000).
In our patient with dementia, there was raised
intracranial tension and widespread parenchymal
involvement of NCC, which may explain the cognitive impairment. NCC presenting with mental disturbances as the sole manifestation is rare. A cause
and effect relationship of NCC with dementia is
doubtful. Fuentes suggested that psychiatric symptoms associated with NCC were not due to the
direct effect of the parasite on a definite region
of the brain but were rather related to mechanical alterations in CSF pressure. Moreover, inflammatory injury of the brain parenchyma may also
play some role (Biswas et al., 1998b). Similarly,
the multiple lesions with perilesional oedema in
the occipital cortex (bilaterally) account for cortical blindness (Fleury et al., 2003). Patients with
unusual clinical manifestations should be investigated more thoroughly using immunodiagnostic
techniques. However, the short period of observation and lack of advanced immunodiagnostic studies
were major limitations of this study.
We conclude that patients from endemic areas
presenting with manifestations discussed above
should have a high index of suspicion for NCC and
must be investigated for it.
Conflicts of interest statement
The authors have no conflicts of interest concerning
the work reported in this paper.

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