Year : 2013  |  Volume : 55  |  Issue : 3  |  Page : 264--267

A study of neuropsychiatric manifestations in patients of neurocysticercosis


Smita Srivastava1, Rakesh Kumar Chadda2, Kiran Bala3, Pradipta Majumdar2,  
1 Department of Psychiatry, Institute of Human Behaviour and Allied Sciences, Delhi, India
2 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
3 Department of Neurology, Institute of Human Behaviour and Allied Sciences, Delhi, India

Correspondence Address:
Rakesh Kumar Chadda
Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India

Abstract

Background: Neurocysticercosis (NCC) is an endemic parasitic infection of Asia, Africa, Latin America, and central Europe. Neuropsychiatric manifestations of the illness include epilepsy and behavioral disturbances. There is a dearth of systematic studies on psychiatric manifestations of NCC from various Asian counties. The present study assessed the prevalence of various psychiatric disorders in a cohort of patients with NCC attending a neurological service. Materials and Methods: Detailed psychiatric assessment was carried out on 50 patients of NCC with epilepsy and 50 patients of epilepsy without any evidence of NCC. Comprehensive Psychopathological Rating Scale was used to elicit the symptoms. Cognitive functions were assessed using Mini Mental Status Examination. Psychiatric diagnoses were made as per International Classification of Diseases, 10 th edition (ICD-10). Results: Sixty eight percent of the patients with NCC suffered from a psychiatric disorder, as compared to 44% of those without NCC (P=0.02). Major depression and mixed anxiety depression were the two most common diagnoses. None of the patients was to found to suffer from a psychotic disorder. The most frequent site of brain lesion of NCC was the parietal lobe, followed by frontal lobes and disseminated lesions. Left sided lesions were associated with greater psychiatric morbidity. Focal seizures with or without secondary generalizations were present more frequently in patients with NCC whereas primary generalized seizures were more common in patients with idiopathic epilepsy (P=0.05). Conclusion: Psychiatric manifestations are more common in patients of epilepsy with NCC than those without NCC. The treating clinician need to be vigilant about the phenomenon.



How to cite this article:
Srivastava S, Chadda RK, Bala K, Majumdar P. A study of neuropsychiatric manifestations in patients of neurocysticercosis.Indian J Psychiatry 2013;55:264-267


How to cite this URL:
Srivastava S, Chadda RK, Bala K, Majumdar P. A study of neuropsychiatric manifestations in patients of neurocysticercosis. Indian J Psychiatry [serial online] 2013 [cited 2021 Sep 23 ];55:264-267
Available from: https://www.indianjpsychiatry.org/text.asp?2013/55/3/264/117146


Full Text

 Introduction



Neurocysticercosis (NCC) is a common neuroparasitic infection with a worldwide distribution. The infection is endemic in rural areas of the developing countries of Asia, Africa, Latin America, and central Europe. [1] Prevalence has been found to be mainly related to socioeconomic factors and feeding habits, especially in Asia and Africa. The illness is especially common in areas where pork is consumed such as Sub-Saharan Africa, India, and in most countries of Southeast Asia. [1],[2],[3],[4] NCC is characterized by the deposition of cysticerci in the brain as a result of eating of undercooked pork. It is the most common parasitic disease of the central nervous system (CNS). [1] NCC is reported to be responsible for nearly half of the late onset cases of epilepsy in the endemic areas, [3] and is also associated with psychiatric manifestations. In an earlier study from Venezuela, nearly 18% of patients admitted to a psychiatric hospital tested positive for cysticercosis on Western Blot test. Most of the positive cases suffered from schizophrenia, organic mental illness, mental retardation, or epilepsy. [5]

Clinical presentation of NCC is diverse and perplexing, varying from an asymptomatic form to a "malignant" form. The polymorphous symptomatology seen in NCC is mimicked only by neuro-tuberculosis and neurosyphilis in India and other developing countries, and multiple sclerosis in the Western countries. Psychiatric symptoms are commonly a part of the clinical presentation of an infectious process. Though psychiatric aspects of classic infectious diseases, such as neurosyphilis and newer infectious diseases such as human immunodeficiency virus (HIV) have been well described in literature and are well researched, psychiatric manifestations of NCC have not been investigated to that extent. [6],[7]

Usual presentation of NCC is with focal seizures or raised intracranial pressure due to internal hydrocephalus. [4],[5] Localizing signs are relatively uncommon, though sudden neurological deficits can result from infarcts. Cases of dementia occurring as a complication of NCC have also been described. [8] Though the disease is endemic in India, there are only a few reports on neuropsychiatric manifestations of the illness from India, [9],[10],[11],[12],[13] with most publications limited to one or two cases. There are reports with NCC presenting as organic psychotic condition, [9],[10] mania, [11] schizophrenia like symptoms [12] or catatonic symptoms. [13] Sporadic cases of NCC have been described on investigations in patients with first episode schizophrenia in the Western world. [14] A study from Brazil [6] found signs of psychiatric morbidity in 66% of the patients with NCC. Depression was the most frequent psychiatric diagnosis followed by psychotic disorder. Eighty eight percent of the patients showed some signs of cognitive decline. In a recent study from Brazil, more than 80% of the patients with NCC reported depressive symptoms. [15]

There a dearth of systematic studies on psychiatric manifestations is in NCC from India, though the illness is endemic. The present study was conducted to study the prevalence of psychiatric morbidity and its clinical correlates in patients with NCC.

 Materials and Methods



Sample selection

The study was conducted at the Institute of Human Behaviour and Allied Sciences, Delhi. Patients presenting with epilepsy in the outpatient clinic or admitted to the inpatient facility of the Neurology services were screened for the study. Inclusion criteria for the case group included age 15-50 years and diagnosis of NCC, based on neuroimaging (computed tomography (CT) scan/magnetic resonance imaging (MRI), wherever feasible) findings, clinical features and immunodiagnostics. Controls were patients with idiopathic epilepsy in the age group 15-50 with no evidence of NCC, based on neuroimaging, clinical features and immunodiagnostics, and no significant abnormality on imaging. Patients with other primary neurological or medical conditions that could present psychiatric symptoms, current alcohol and substance abuse (other than nicotine use) and those refusing consent were excluded from the study. Fifty cases and 50 controls were recruited for the study.

Assessments

Socio-demographic and clinical information was collected on a semistructured proforma designed for the study. Detailed psychiatric history was taken and clinical diagnosis was made in discussion with a consultant psychiatrist. Psychiatric symptomatology was also assessed using the Comprehensive Psychopathological Rating Scale (CPRS). [16] Cognitive functions were assessed on the Mini Mental Status Examination (MMSE). [17] Diagnosis was made according to International Classification of Diseases, 10 th edition (ICD-10) criteria.

Written informed consent was taken from the patients. In subjects less than 18, consent was taken from the parents. The study was approved by the Institute's ethics committee.

Statistical analysis

Frequency distribution tables were prepared. The two groups were compared on various demographic and clinical variables. Chi square, Fisher Exact and t test statistics were applied wherever appropriate.

 Results



Sample consisted of 50 cases and 50 controls. Thirty one (62%) subjects in the case group belonged to the age range 15-25 and 13 (26%) to the age range 26-35. The corresponding figures for the controls were 43 (86%) and three (6%), respectively. Sixty four percent of the subjects each in both the groups were males. Twenty six (52%) subjects in the case group and 39 (78%) in the control group were never married. Forty six (92%) cases and 39 (78%) controls were Hindus and the rest were Muslims. Sample was predominantly urban with 78% of the cases and 86% of the controls belonging to the urban background. About half of the subjects in both the groups had studied for less than 10 years. Only one of the subjects was a graduate. There were no significant differences between the case and control group on various socio-demographic characteristics.

[Table 1] compares the prevalence of psychiatric morbidity between cases and controls. Thirty four (68%) patients from the case group received a psychiatric diagnosis, compared to 22 (44%) from the control group (P=0.02). Major depression was the most frequent diagnosis in both cases (36%) as well as controls (30%), followed by mixed anxiety depression diagnosed in 18% and 10% of the cases and controls, respectively. None of the patients suffered from a psychotic disorder. A few patients in the case group received other diagnoses like agoraphobia, panic disorder, generalized anxiety disorder, and others.

Lesions of NCC were present in 39 cases out of 50, out of whom 25 patients had a psychiatric diagnosis. Parietal area was the most commonly affected area (34%), followed by frontal (24%) area. In 22% cases, the lesions were disseminated. In seven (14%) cases, fronto-parietal or temporo-parietal areas were affected. In patients with a psychiatric diagnosis, 17 had a left sided lesion, seven had a right sided lesion and one had disseminated lesions. Patients having a lesion on the dominant side were more likely to suffer from a psychiatric disorder (P=0.05).{Table 1}

Patients in the case group scored higher on CPRS items like apparent sadness (P=0.03), inner tension (P=0.012), hypochondriasis (P=0.03), phobia (P=0.009), falling memory (P=0.002), increased sleep (P=0.004), slowness of movements (P=0.04) muscular tension (P=0.000), autonomic disturbances (P=0.000), aches and pains (P=0.04), and slowness of movements (P=0.04).

Scores on MMSE ranged from 15 to 30 in cases (Mean 25.22±3.91) as well as in controls (Mean 25.18±3.43). There was no significant difference between the two groups. No significant difference was also observed on MMSE scores between the cases with and without psychiatric disorder.

Subjects in the case group showed a higher frequency of partial seizures with or without generalization (24, 48%), compared to the control group (12, 24%) (P=0.05). Primary generalized seizures were more common in controls having idiopathic epilepsy (36, 72%) controls, as compared to the case group (24, 48%).

 Discussion



NCC is the most important neurological disease of parasitic origin in humans. It is known to be a leading cause of epilepsy in endemic areas like India. The disease can also present as unfamiliar manifestations like disordered behavior, transient paresis, intermittent obstructive hydrocephalus, disequilibrium, meningoencephalitis, involuntary movements, failing vision, and mental disturbances. [1] Focus in the present study was on psychiatric morbidity in patients of epilepsy with NCC.

We found psychiatric morbidity in 68% of the patients of epilepsy with NCC, which was significantly higher than the control group of patients of epilepsy without NCC. There was no difference in cognitive functions between the cases and controls, though both showed some cognitive decline in form of MMSE score of about 25. In an earlier study on psychiatric morbidity in NCC from Brazil, psychiatric symptoms and cognitive decline were observed in 65.8 and 87.5% of the cases respectively. Depression was the most frequent psychiatric diagnosis, seen in 52.6% of cases and psychotic disorders were diagnosed in 14.2%. [6] Our sample was relatively younger with 88% of the patients in the age group of 15-34, as compared to the Brazilian sample which had a mean age of 36.7 years with a range of 18-60. However, mean MMSE score of our cases (25.22, range 15-30) was comparable to the Brazilian sample (26.9, range 12-30). This Brazilian study had a limitation of not having a control group.

Prevalence of overall psychiatric morbidity was higher in the patients with NCC than those without NCC, though we could not get significant differences in the individual diagnostic categories due to small numbers in the individual categories. Major depression and mixed anxiety depression were the two most common diagnoses, constituting 36% and 18% of the sample, respectively, which was slightly higher than 30% and 5.5% in the control group. The presence of high prevalence of depression among controls can be explained by the fact that depression can be a consequence of epilepsy. One recent study from Brazil also found a high prevalence of depressive symptoms in epilepsy patients, in fact higher than those having epilepsy with NCC. [15] Depressive symptoms were also common in the controls to the extent of 100% in headache cases, 92% in epilepsy patients, but lower (83-88%) in the NCC group. [15] The study had an important limitation of assessing depression only using the Hamilton Rating Scale of Depression and not carrying out a clinical evaluation.

Our patients with NCC scored higher on CPRS items like inner tension, hypochondriasis, phobia, lassitude, failing memory, increased sleep, reduced sexual interest, autonomic disturbances, aches and pains, and loss of sensation or movement as compared to controls. Most of these symptoms belong to the neurotic spectrum. The finding is comparable to the study by Forlenza et al., [15] in which 75% of cases had Present State Examination (PSE) sub-scores suggesting non-specific neurotic syndromes. None of our patients reported psychotic symptoms or received a psychotic diagnosis, though Forlenza et al., [6] had found symptoms suggestive of schizophrenia in four cases.

Parietal lobe was the most affected area in our cases, followed by frontal lobe and disseminated lesions. Left sided lesions were associated with more psychiatric morbidity, explained by the fact that a lesion of NCC on the dominant side accounted for the morbidity. The patients with NCC had more focal seizures due to the presence of a focus, whereas patients with idiopathic epilepsy had primary generalized seizures. The finding is consistent with the earlier literature. [3],[4]

 Conclusion



Psychiatric manifestations are more common in patients of epilepsy with NCC than those without NCC. NCC can lead to a range of psychiatric symptoms, mostly in the non psychotic spectrum. It is important to consider NCC in differential diagnosis of patients in endemic areas presenting with psychiatric symptoms, especially those showing poor response to the standard treatment and in those with history of seizures. Studies with larger sample are required.

 Acknowledgment



The authors are grateful to Dr. Narander Singh, former assistant professor of psychiatry and Dr. Rajeev Thakur, professor of microbiology, Institute of Human Behaviour and Allied Sciences, Delhi 110 095, India for their kind help in the study.

References

1Del Brutto OH, Sotelo J. Neurocysticercosis: An update. Rev Infect Dis 1988;10:1075-87.
2Wallin MT, Kurtzke JF. Neurocysticercosis in the United States: Review of an important emerging infection. Neurology 2004;63:1559-64.
3Pal DK, Carpio A, Sander JW. Neurocysticercosis and epilepsy in developing countries. J Neurol Neurosurg Psychiatry 2000;68:137-43.
4García HH, Gonzalez AE, Evans CA, Gilman RH. Cysticercosis Working Group in Peru. Taenia solium cysticercosis. Lancet 2003;362:547-56.
5Meza NW, Rossi NE, Galeazzi TN, Sánchez NM, Colmenares FI, Medina OD, et al. Cysticercosis in chronic psychiatric inpatients from a Venezuelan community. Am J Trop Med Hyg 2005;73:504-9.
6Forlenza OV, Filho AH, Nobrega JP, Machado LD, de Barros NG, de Camargo CH, et al. Psychiatric manifestations of neurocysticercosis: A study of 38 patients from a neurology clinic in Brazil. J Neurol Neurosurg Psychiatry 1997;2:612-6.
7Schneider RK, Robinson MJ. Psychiatric presentations of non-HIV infectious diseases: Neurocysticercosis, lyme disease, and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection. Psychiatr Clin North Am 2002;25:1-16.
8Ramirez-Bermudez J, Higuera J, Sosa AL, Lopez-Meza E, Lopez-Gomez M, Corona T. Is dementia reversible in patients with neurocysticercosis? J Neurol Neurosurg Psychiatry 2005;76:1164-6.
9Mahajan SK, Machhan PC, Sood BR, Kumar S, Sharma DD, Mokta J, et al. Neurocysticercosis presenting with psychosis. J Assoc Physicians India 2004;52:663-5.
10Trivedi JK, Singh RK, Dalal PK. Psychiatric manifestations of cysticercosis: Review of literature and case report. Indian J Psychiatry 1983;25:74-7.
11Mishra BN, Swain SP. Psychiatric morbidity following neurocysticercosis. Indian J Psychiatry 2004;46:267-8.
12Bhatia B, Mishra S. Neurocysticercosis presenting as schizophrenia: A case report. Indian J Psychiatry 1994;36:187-9.
13Aggarwal V, Kumar P, Chadda RK. Neurocysticercosis: Uncommon presentation. Indian J Pediatr 2001;68:34-5.
14Johnstone EC, Macmillan JF, Crow TJ. The occurence of organic disease of possible or probable aetiological significance in a population of 286 cases of first episode schizophrenia. Psychol Med 1987;17:371-9.
15Almeida SM, Gurjão SA. Frequency of depression among patients with neurocysticercosis. Arq Neuropsiquiatr 2010;68:76-80.
16Asberg M, Montgomery SA, Perris C, Schalling D, Sedvall G. A comprehensive psychopathological rating scale. Acta Psychiatr Scand Suppl 1978;271:5-27.
17Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.