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   Table of Contents      
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 33-35

Postpartum Seizure Due to Neurocysticercosis: A Case of Diagnostic Dilemma


1 Department of Anaesthesia, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
2 Department of Anaesthesia, AIIMS, Rishikesh, India

Date of Web Publication30-Apr-2019

Correspondence Address:
Dr. Bhavna Gupta
Quarter 2B, AIIMS Campus, Rishikesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_11_19

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  Abstract 


Seizure in early postoperative period in a postpartum female always poses diagnostic dilemma for both the anesthetist and the surgeon. We are reporting a 30-year-old primigravida with unremarkable history, except for few readings of high blood pressure during antenatal period who developed convulsions within 1 hour of delivery performed by lower segment cesarean section under spinal anesthesia. All relevant causes of postpartum seizure were ruled out and surprisingly magnetic resonance imaging of brain revealed cerebral neurocysticercosis; appropriate management and timely intervention resulted in uneventful recovery. The clinical manifestations of neurocysticercosis are variable and depend on the number, size, and location of cysts and the immune response of the host.

Keywords: cerebral neurocysticercosis, postpartum


How to cite this article:
Gupta L, Gupta B. Postpartum Seizure Due to Neurocysticercosis: A Case of Diagnostic Dilemma. MAMC J Med Sci 2019;5:33-5

How to cite this URL:
Gupta L, Gupta B. Postpartum Seizure Due to Neurocysticercosis: A Case of Diagnostic Dilemma. MAMC J Med Sci [serial online] 2019 [cited 2019 Dec 8];5:33-5. Available from: http://www.mamcjms.in/text.asp?2019/5/1/33/257419




  Introduction Top


There are numerous causes of postpartum seizure disorder and there may be an overlap of symptoms making diagnosis and treatment difficult. We present a unique case of postpartum seizure disorder in which the patient was diagnosed to have neurocysticercosis (NCC) as evident from magnetic resonance imaging (MRI) of the brain; this case report highlights many of the other differential diagnosis of postpartum seizure and its timely management. NCC is a parasitic infection caused by Taenia solium and occurs due to ingestion of contaminated pork. It is a leading cause of seizures in the developing world. Symptoms may be secondary to live or degenerating cysts, or previous infection causing calcification or gliosis. The most common affected site is the brain parenchyma that can precipitate seizures.


  Case Report Top


A 30-year-old unbooked primigravida presented in labor with fetal distress for emergency lower segment cesarean section. There was no history of any comorbidity except for past history of on and off episodes of headache, relieved with paracetamol. She also had few records of high blood pressure in the late third trimester in the range of 150 to 160 mmHg systolic and 90 to 110 mmHg diastolic. She had mild pedal edema, although urinalysis for protein was negative, and liver function test and platelet count were normal. After wheeling inside operation theater, spinal anesthesia was given and sensory level of T6 dermatome was achieved. After an uneventful caeserian section, she was transferred to the postanesthesia recovery room with stable vitals. After nearly 30 minutes in the postoperative area, she complained of severe headache followed by an episode of generalized tonic clonic convulsions that lasted for 60 seconds, followed by postictal confusion. There was no history of tinnitus, neck rigidity, and raised temperature or visual disturbance. Vitals were essentially stable during this seizure episode. Immediately, midazolam injection 2 mg intravenously was administered along with oxygenvia face mask. All routine investigations were sent to find out a possible cause and neurological consultation was sought. Her immediate blood investigations suggested normal arterial blood gases, blood sugar 118 mg/dL, sodium 132 meq/L, potassium 3.61 meq/L, calcium 0.91 mg/dL, and magnesium 2.1 mg/dL. Magnesium sulfate injection 4 g in 100-mL normal saline was given slowly intravenous, followed by infusion of 1 g/h for next 24 hours. She was also put on levetiracetam injection 500 mg twice daily. On the next postoperative day, contrast-enhanced magnetic resonance imaging (CEMRI) of the brain was done on the advice of the neurologist. In CEMRI of the brain, multiple well-defined ring enhancing altered signal intensity lesion was noted with mild perilesional edema, suggestive of infective granuloma NCC [[Figure 1]]. There was no evidence of papilledema/intraocular cysticercosis on ophthalmological examination. Her electroencephalogram was normal. A diagnosis of postpartum seizure disorder complicated with NCC of the brain was made after MRI and antiparasitic agents were also added. The patient was discharged on fifth postoperative day on appropriate treatment without any further episode of seizure and history taken later on revealed frequent ingestion of pork in their family. MRI performed 6 weeks later confirmed the resolution of edema surrounding the calcified cyst.
Figure 1: Axial T2 contrast-enhanced MRI brain precontrast and postcontrast, suggesting multiple well-defined ring enhancing altered signal intensity lesion noted with mild perilesional edema, suggestive of infective granuloma neurocysticercosis.

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  Discussion Top


Seizure in early postoperative period poses diagnostic dilemma for anesthesiologists and surgeons. In our case, the patient had seizure in the immediate postoperative period, so various clinical conditions, administered drugs, electrolyte disturbances, hypoglycemia, previous medical history, and effect of spinal anesthesia must be kept in consideration while making an immediate provisional diagnosis. Puerperal seizures associated with postdural puncture headache have been reported as a cause of late onset seizure in postoperative period.[1] But in this patient, seizure occurred within half hour after surgery, so possibility of seizures secondary to postdural puncture is unlikely. Seizure due to amniotic fluid embolism can occur in immediate postpartum period, after cesarean section, but is usually associated with dyspnea and hemodynamics instability.[2] Negative D-dimer test further ruled out any possibility of amniotic fluid embolism. From obstetrician point of view, postpartum convulsions are mainly due to pregnancy-induced hypertension or eclampsia, although urinalysis for protein was negative, and liver function test and platelet count were normal. Headache is regarded as “normal symptom” during pregnancy.[3] Only a meticulous detailed history along with vital monitoring and past medical history can help in making diagnosis of exclusion to rule out eclampsia from other disorders in such patients. Classical presentation of headache followed by convulsions pointed toward some brain pathology that was missed preoperatively, also as it was an emergency, complete workup was impossible. With such atypical features and sudden worsening of clinical status in the postoperative period, an early neuroimaging becomes important. In our case, CEMRI showed multiple foci of T2/fluid-attenuated inversion recovery signal of hyperintensity in contrast images consistent with the diagnosis of cerebral NCC.

The clinical manifestations of cysticercosis infestation are determined by site and stage of infection. Although fully viable cystic lesions usually remain subclinical or asymptomatic, decaying and dead cysts (granulomas/calcifications) are associated with perilesional inflammation and seizures.[4] This may sometimes manifest as seizures (occasional/recurrent), obstructing ventricular lesions (hydrocephalus), and mass effects (stroke). Diagnosis is usually made on the basis of clinical suspicion further strengthened by cranial imaging (or MRI) and immunological testing. The calcified lesions have a propensity to cause perilesional edema through disruption of the blood–brain barrier.[5] The sudden onset of seizure with headache in postpartum period can be explained by facts that in pregnancy, there is enhancement of local phagocytosis and neutrophilic and monocytic activity around the cysticerci leading to inflammation along with pregnancy hormonal-induced angiogenic stimuli contributing to enhanced blood–brain barrier permeability leading to seizure activity. Some component of pregnancy-induced hypertension as evident by high BP in the preoperative period may also have contributed to perilesional cerebral edema leading to sudden onset seizures along with headache. Severe headache itself in the postoperative period is a very important symptom and includes differential diagnosis of postdural puncture headache, impending eclampsia and even NCC.[5] There is paucity of literature with respect to pregnancy-induced reactivation of NCC during postpartum period; there is a possibility of a shift toward an increase in immune response and manipulation of hormones by helminths that may increase their survival and parasite density. So, a cause should be ascertained as soon as possible by clinical history, physical examination, vitals charting, and neuroimaging.


  Conclusion Top


NCC is one of the common etiologies of seizures and should be considered in differential diagnosis as a possible cause of postpartum seizures that cannot solely be explained by eclampsia. Neuroimaging like MRI plays an important role in diagnosis but supportive treatment must be promptly initiated to prevent further neurological sequel.

Financial support and sponsorship

Nil.

Conflicts on interest

There are no conflict of interest.



 
  References Top

1.
Rice I, Mountfield J, Radhakrishnan D, Nelson-Piercy C. Puerperal seizures associated with post dural puncture headache. Int J Obstet Anesth 2003;12:126-9.  Back to cited text no. 1
    
2.
Ducloy-Bouthors AS, Wantellet A, Toumouys A, Depret S, Krivosic-Horber R. Amniotic fluid embolism in a case of seizure and mild uterine haemorrhage, Ann Fr Anesth Reanim 2004;23:149-52.  Back to cited text no. 2
    
3.
Aegidius K, Zwart JA, Hagen K, Stovner L. The effect of pregnancy and parity on headache prevalence: the Head-HUNT study. Headache 2009;49:851-9.  Back to cited text no. 3
    
4.
Webb CM, White AC Jr., Update on the diagnosis and management of neurocysticercosis. Curr Infect Dis Rep 2016;18:44.  Back to cited text no. 4
    
5.
Gupta L, Dwivedi G, Bhadoria P. Neurocysticercosis: an unusual incidental diagnosis of postdural puncture headache. Indian J Anesth Analg 2015;2:53-6.  Back to cited text no. 5
    


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