Unusual presentation of more common disease/injury

CASE REPORT

Avoiding misdiagnosis: cystic calcified brain
metastases of uterine cervical cancer mimicking
neurocysticercosis
Jacopo Fantini, Arianna Sartori, Paolo Manganotti
Department of Medical,
Surgical and Health Sciences,
Neurology Clinic, University of
Trieste, Trieste, Italy
Correspondence to
Dr Jacopo Fantini, jacopo.
fantini@gmail.com
Accepted 24 January 2017

SUMMARY
The radiological finding of multiple calcified brain
lesions is atypical for brain metastases and in absence
of a clear evidence of disseminated neoplastic disease
the differential diagnosis may be difficult. Calcified
brain metastases (CBM) are rarely encountered in
clinical practice and they mostly arise from lung, breast
and gastrointestinal primitive tumours. Only one case
of uterine cervical carcinoma (UCC) with CBM has
been reported so far. We describe the case of a 41year-old Caucasian woman with a history of
hysterectomy and bilateral salpingo-oophorectomy for
UCC 3 years prior to observation and no evidence of
neoplastic recurrence that developed cystic CBM.
Owing to their peculiar radiological appearance, lesions
were initially misidentified as neurocysticercosis, the
most common parasitic infection of the central nervous
system. We offer the reader some important teaching
points for the differential diagnosis and discuss the
rarity of our case.
BACKGROUND
Neurocysticercosis (NC) is the most common parasitic infection of the central nervous system (CNS)
and it is a well-known mimicker of a variety of
neurological conditions.1
Diagnosing NC can be a challenge in nonendemic countries, given the rarity of the disease
and the multifaceted presentation.1 2
In this article we present the second case of calcified brain metastases (CBM) arising from a primary
uterine cervical carcinoma (UCC) that were initially
misdiagnosed as NC.

CASE PRESENTATION

To cite: Fantini J, Sartori A,
Manganotti P. BMJ Case
Rep Published online:
[please include Day Month
Year] doi:10.1136/bcr-2016217952

We report the case of a 41-year-old Caucasian
woman with a history of UCC (stage IB G2,
International Federation of Gynecology and Obstetrics
classification) treated with hysterectomy and bilateral salpingo-oophorectomy and lymphadenectomy
3 years prior to observation and no evidence of
neoplastic recurrence. The patient was not on any
medical therapy and denied other relevant diseases.
The patient presented in the emergency room
after she had experienced left hemibody focal
motor seizures with secondary generalisation.
She reported no other symptoms, denied recent
travels out of the country and use of illicit drugs.
Neurological examination revealed a right superior
quadrantopsia. A complete physical examination
and chest radiography were normal.

INVESTIGATIONS
A cerebral CT showed the presence of multiple
supratentorial and infratentorial hyperdense
lesions, located near the cortical surface and in the
deep grey matter, without significant enhancement
after contrast administration and no mass effect,
the biggest one located on right parietal–occipital
parafalcine region (figure 1).
Brain MRI confirmed more than 10 roundshaped lesions of cystic appearance, hypointense
on T2-weighted and diffusion-weighted image
sequences, with a thin peripheral rim enhancement
after gadolinium administration. Few lesions had a
subependimal position in the lateral ventricles. The
biggest cyst showed a mixed intensity, suggesting
the presence of an air–liquid interface. There were
no signs of perilesional oedema or mass effect
(figure 2).
Laboratory test showed normal blood cell count,
normal acute phase proteins levels and the analysis
of the T-cell subsets showed no clonal abnormalities. The patient had no signs of immunodepression and testing for tuberculosis and HIV were
negative. Other tests for parasitic disease including
cryptococcal antigen, toxoplasma gondii antibodies
and specific enzyme-linked immunoelectrotransfer
blot (ETIB) assays for NC were normal.
Cerebrospinal fluid (CSF) examination, including
cytology, cultural tests, PCR for neurotropic viruses
and ELISA for NC were negative. Neoplastic
markers showed an increase in tissue polypeptide
antigen (304 U/L), and a mild increase of neuronspecific enolase. An ophthalmological examination
was normal.
CT of the chest revealed millimetric scattered
nodules the biggest (12 mm diameter) located at
the right hilum and some isolated mediastinal
lymph nodes of increased size without pleural effusion. CT of the abdomen showed no metastatic
lesions.
In a follow-up MRI performed 7 weeks later,
new lesions were seen and some of the previously
described ones were increased in volume (figure 3).
One and a half months later a wedge lung resection
performed by minimally invasive video-assisted
thoracoscopy was performed to remove a small
portion of the lung containing the suspicious
nodules without removing a complete lung lobe.
Histology revealed a moderately differentiated
squamous cell carcinoma with necrotic aspects and
it was compatible with the diagnosis of UCC
metastases.

Fantini J, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2016-217952

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Unusual presentation of more common disease/injury

Figure 1 Non-enhanced CT scan. Hyperdense lesions on (A) right
cerebellar hemisphere, (B) right posterior hypothalamus and right
frontal lobe and (C) right parietal–occipital lobe.

OUTCOME AND FOLLOW-UP
The patient received whole brain radiotherapy (WBRT) and systemic chemotherapy and survived for 18 months. Postmortem
examination of brain lesions confirmed the diagnosis of CBM.

DISCUSSION
The presence of multiple calcified cystic lesions, the absence of
oedema or mass effect and the involvement of the subependimal
space are atypical for brain metastases and suggested the
hypothesis of NC, a CNS infection by tapeworm Taenia solium
at the larval stage.3
NC is endemic in many low-income countries of Latin
America, sub-Saharan Africa and Asia and the infection usually
occurs after the ingestion of undercooked pork meat.1 4
Although our patient denied recent travels and was not immunodepressed, NC may be asymptomatic for years and affect
immunocompetent people.1
The evolution of NC lesions can be summarised by neuroimaging studies: in the earlier vesicular-colloidal stages, lesions have
cystic appearance and may show a peripheral enhancement. In
the granular and nodular stages, the cysts tend to retract and
can be surrounded by oedema, then evolving in calcified remnants in the later phases.1
Two main radiological features can help in the diagnosis of
NC: the first is the recognition of the scolex, which presents as
an eccentric focus of enhancement attached to the cystic wall;
the second is the demonstration of lesions in different stages of
evolution.5
However, the scolex—whose finding has a pathognomonic
value—was not visible on MRI and the presence of lesions of
different sizes was not sufficient to outline different evolutive
stages. In fact, the MRI characteristics of our patients’ CT
hyperdense lesions mimicked NC at the vesicular-colloidal
stage, when they are usually not calcified.
The negativity of serology and CSF assays for NC confirmed
this theory. The sensitivity of ETIB assays approaches 98% in

Figure 2 Gadolinium-enhanced T1-weighted MRI. Cystic lesions are
seen on (A) right posterior hypothalamus and right frontal lobe (see
figure 1B), (B) subependimal space of the left lateral ventricle, (C) right
parieto-occipital cortex (see figure 1C).
2

Figure 3 T2-weighted fluid-attenuated inversion recovery MRI.
Multiple hypointense lesions on (A) bilateral cerebellar hemispheres
and right temporal pole. (B) enlarged cyst on right posterior
hypothalamus and on (C) right parieto-occipital cortex with fluid level
(see figure 1C and figure 2C).
patients with two or more live parasites and therefore negative
results in patients with multiple viable cysts are virtually
impossible.5 6
A previous history of UCC raised our suspicion for metastases
despite the apparent disease remission and negative general
examination and chest X-ray.
We documented the second case of CBM secondary to UCC.7
The rarity of our finding is magnified by the low incidence of
UCC cerebral metastases (0.6%),8 and the few available descriptions of CBM from other sites.9 Brain can rarely be the first
localisation of metastatic UCC being involvement of other
distant sites (eg, lungs) more common.10 On the contrary, pulmonary localisations of NC are exceptional and occur only after
widespread dissemination to CNS, muscle and eye.1
Similarly to the previous report the histology revealed squamocellular carcinoma and the patient had a relatively long survival, confirming a milder prognosis for CBM compared with
non-calcified brain metastases.7 8
WBRT alone or with chemotherapy appears a reasonable
option for multiple CBM but no standardised approach exists.
We must acknowledge that a brain biopsy could be considered
to exclude the presence of two concomitant diagnoses (eg, pulmonary metastatic disease and parasitic cerebral involvement).
In accordance with the patient preference we avoided another
unpleasant invasive procedure and in line with our expectations
the postmortem examination of brain lesions confirmed the
diagnosis of CBM.
Diagnosis of NC should rely on published guidelines and
empirical antiparasitic treatments should not be used to bypass
clinical reasoning.
CBM are rare and can originate from UCC and mimic NC.
An accurate differential diagnosis is mandatory in order to avoid
treatment delays and unnecessary interventions.

Learning points
▸ We presented the second case of calcified brain metastases
of uterine cervical cancer.
▸ Calcified brain metastases might have cystic appearance and
mimic neurocysticercosis, the most common parasitic
infection of the central nervous system.
▸ Important clues for the diagnosis of neurocysticercosis are
the radiological identification of the scolex and the
demonstration of lesions at different evolutive time points.
▸ A negative serology in a patient with multiple cysts almost
always excludes the diagnosis of neurocysticercosis.
▸ Calcified brain metastases tend to have a slow progression.

Fantini J, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2016-217952

Unusual presentation of more common disease/injury
Contributors JF acquired the data. JF and AS participated in the conception and
design of the paper and drafted the manuscript. JF, AS and PM interpreted the data,
revised the manuscript for intellectual content and approved the final version of the
manuscript.
Competing interests None declared.

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Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.

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3

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Omuro AM, Leite CC, Mokhtari K, et al. Pitfalls in the diagnosis of brain tumours.
Lancet Neurol 2006;5:937–48.

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10

WHO. First WHO report on neglected tropical diseases. Geneva; World Health
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Del Brutto OH, Rajshekhar V, White AC Jr, et al. Proposed diagnostic criteria for
neurocysticercosis. Neurology 2001;57:177–83.
Tsang VC, Brand JA, Boyer AE. An enzyme-linked immunoelectrotransfer blot assay
and glycoprotein antigens for diagnosing human cysticercosis (Taenia solium).
J Infect Dis 1989;159:50–9.
Gaze MN, Gregor A, Whittle IR, et al. Calcified cerebral metastasis from cervical
carcinoma. Neuroradiology 1989;31:291.
Piura E, Piura B. Brain metastases from cervical carcinoma: overview of pertinent
literature. Eur J Gynaecol Oncol 2012;33:567–73.
Kawamura D, Tanaka T, Fuga M, et al. Slow progression of calcified cerebellar
metastasis from ovarian cancer: a case report and review of the literature. Neurol
Med Chir (Tokyo) 2013;53:722–6.
Sato Y, Tanaka K, Kobayashi Y, et al. Uterine cervical cancer with brain
metastasis as the initial site of presentation. J Obstet Gynaecol Res 2015;41:
1145–8.

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Fantini J, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2016-217952

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