Commentary

Cysticercosis is an important cestode infection. It can be seen in tropical world and becomes a concern in tropical medicine. This infection is a tissue-embedded parasitosis. The infection can be seen at any organs in human body including neurological system. Neurocysticercosis is considered a serious form of cysticercosis. Neurocysticercosis can induce the neurological manifestations and can be deadly. Due to the nature of tissue invasiveness, the parasitic cyst can be seen anywhere in central nervous system. It is suggested that neurocysticercosis should be included in differential diagnosis of any patients from tropical areas who present with neurological problems.[1]

The main part of central nervous system that is usually affected is the cerebral cortex. However, the involvement of other locations can be expected. The pontine involvement in neurocysticercosis is uncommon. This can be difficult for diagnosis. In the recent publication in the journal, an interesting case presenting with Millard Gubler syndrome was reported.[2] Indeed, the ventral pontine syndrome is a rare syndrome, and it is usually due to the infarction.[3] The infectious etiology has not been clearly mentioned. Focusing on pontineneurocysticercosis, the neurological signs, and symptoms are usually due to the mass effect. Cranial nerve deterioration can be expected. There are some previous case reports on pontineneurocysticercosis-induced cranial nerve palsy.[45] However, there is no complete report on Millard Gubler syndrome.

Indeed, the diagnosis of Millard Gubler syndrome is usually based on neurological imaging. Magnetic resonance angiography findings usually show infarction.[6] However, the unexpected lesion as parasitic cyst might be seen as in the present case. Indeed, imaging studies are recommended in all patients with cranial nerve neuralgia before starting any treatment.[4] The exact final diagnosis has to be derived before any treatment since there are large difference in clinical therapeutic guidelines.

Finally, there are some facts to be noted:

• Neurocysticercosis is an important tropical neurological infection that is reported sporadically. Hence, it should be in differential diagnosis of any cases with neurological problems in the tropical.

• Neurocysticercosis can be silent and chronic progressive. The clinical manifestations might be delayed.

• The unusual clinical manifestation of neurocysticercosis can be expected. The cranial nerve palsy is a good example. Not only the Millard Gubler syndrome, but also other neurological syndrome, such as Claude's syndrome,[7] can be the first clinical presentation.

• Although parasitic cyst is detected, it does not mean that it is the cause of neurological problem but accidental finding. Before making final decision that neurological manifestation is due to the neurocysticercosis, the other causes must be found out. Also, it can be said that the concomitant occurrence can be expected.