Isolated Echinococcus granulosus hydatid cyst in the CNS with severe reaction to treatment

To the Editor: Hagemann et al.1 presented a case of cerebral Echinococcus granulosus with a severe meningeal inflammatory reaction caused by praziquantel (PZQ) and albendazole treatment who eventually recovered. The authors suggested that concomitant corticosteroid therapy, as used in neurocysticercosis, might minimize a severe reaction. We wish to report a fatal outcome in a patient with neurocysticercosis who was treated with PZQ and corticosteroid. A 66-year-old man was hospitalized with several days of head ache and confusion. Examination showed an alert, dysarthric man, without neck stiffness or papilledema. A nonenhanced CT scan of the head was unremarkable, without calcifications or cysts. Contrast enhanced CT revealed multiple focal-enhancing lesions (figure) with mild edema. Magnetic resonance imaging of the head with gadolinium was reported as most consistent with cysticercosis. A lumbar puncture showed an opening pressure of 180 mm Hg. There were 90 leukocytes, with a differential of 45% neutrophils, 40% lymphocytes, and 1% eosinophils. The protein was elevated at 90 mg/dL, with a normal glucose of 29 mg/dL. Cysticercosis serology (immunoblot) was positive from the spinal fluid. Figure. Contrast-enhanced CT scan before praziquantel treatment showing multiple-enhancing cysticercal lesions. Dexamethasone, 2 mg twice daily, was started. The next day, PZQ was started at a dose of 50 mg/kg/day (1.5 gm tid). Three days after the start of PZQ, …