DIAGNOSTIC CHALLENGES AND OUTCOMES OF EMPIRICAL THERAPY FOR NEUROCYSTICERCOSIS IN AN UNTREATED HIV PATIENT

This case report describes a 35-year-old woman, Jane Doe (JD), who recently immigrated to Miami, Florida from Latin America and presented to the emergency department after a witnessed seizure. She reported one prior seizure seven years earlier in her home country, for which she did not receive anti-seizure therapy. JD also disclosed a 16-year history of human immunodeficiency virus (HIV) infection and had been off treatment for the past five years. An extensive workup for potential infectious etiologies—including tuberculosis, syphilis, toxoplasmosis, cytomegalovirus, herpes simplex virus, strongyloidiasis, and hepatitis—was negative. Magnetic resonance imaging revealed multiple calcified supra- and infratentorial lesions with vasogenic edema and internal septations. Given these findings and JD’s history of HIV infection and residence in an endemic region prior to immigration, the differential diagnosis included central nervous system (CNS) lymphoma, toxoplasmosis, and neurocysticercosis (NCC). Diagnosis was complicated by her advanced HIV disease, negative serologic testing, and the broad differential diagnosis for multiple ring-enhancing lesions in immunocompromised patients. JD’s presentation met Infectious Diseases Society of America criteria for NCC. She was started on a 14-day course of albendazole and praziquantel, as well as levetiracetam for seizure prevention and Biktarvy and Bactrim for HIV management. She was discharged after 12 days with plans for outpatient follow-up. This case underscores the importance of considering NCC in patients with untreated HIV infection and relevant epidemiologic exposures, even when serologic testing is negative.