January 2004: elderly Filipino man with frontal lobe tumor

A 74-year-old Filipino man presented with new-onset partial-complex seizures. Eight months earlier he had a subtotal gastrectomy for adenocarcinoma classified as T1 N0M0 stage IA. He was irradiated. Two months later, he became confused and developed rhythmic, seizure-like movements of the extremities. A head CT revealed a 2 cm. right frontal lobe mass. On MRI, the mass exhibited ring enhancement and was surrounded by edematous white matter. The patient denied headache, weakness or constitutional symptoms. CT of the chest and abdomen revealed no evidence of metastatic spread or other abnormalities. His seizures were controlled with fosphenytoin and dexamethasone. Preoperatively the frontal lobe lesion was considered most likely to be either a metastatic or primary tumor. Resection of the frontal lobe lesion revealed a firm gliotic cystic mass. Crush preparations and frozen sections showed acute and chronic inflammation, gliosis, fibrosis, and many foreign body giant cells reacting to parasitic larval tissue. Intact and necrotic larval parts were surrounded by gliotic brain tissue containing foreign body giant cells, macrophages, and lymphocytes. However, eosinophils were not seen. Finally a refractive fragment resembling a hooklet and a fragmented scolex were identified that made a diagnosis of cysticercosis certain.