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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 230-233

Anterior orbital cysticercosis: A case presentation


Department of Ophthalmology, Andaman and Nicobar Islands Institution of Medical Sciences, Andaman and Nicobar Islands, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Sujit Das
Department of Ophthalmology, Andaman and Nicobar Islands Institution of Medical Sciences, Port Blair, Andaman and Nicobar Islands - 744 104
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_90_17

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  Abstract 


One of the most important parasites which frequently cause blindness in humans is the cysticercus cellulosae. Cysticercus cellulosae, the larval form of the pork tapeworm Taenia solium, is the causative organism of cysticercosis, in which humans are the intermediate hosts in the life cycle. Cysticercus cellulosae may become encysted in various bodily tissues, usually the eyes, central nervous system, and subcutaneous tissues. An immunologic reaction with fairly intense inflammatory signs and symptoms may be produced, and the surrounding structures may be compressed. Acquired strabismus, diplopia, recurrent redness, and painful proptosis are some of the clinical signs in patients with orbital cysticercosis. Diagnosis of cysticercosis is based mainly on orbital imaging because of its highly specific appearance. Medical therapy is the main stay of treatment. Cysticercosis is the infestation by cysticercus cellulosae, the larval form of the pork tapeworm, T. solium. It is contracted by ingestion of the infective cysticerci in under cooked pork; ingestion of eggs of T. solium in contaminated water, food, or vegetables; and regurgitation of eggs from the small intestine. The sites for predilection for the development of cysticerci are the central nervous system, subcutaneous tissue, skeletal muscle, heart muscle, and the eye.

Keywords: Cysticercus, parasitic infection of eye, tape worm and eye


How to cite this article:
Das S. Anterior orbital cysticercosis: A case presentation. Kerala J Ophthalmol 2017;29:230-3

How to cite this URL:
Das S. Anterior orbital cysticercosis: A case presentation. Kerala J Ophthalmol [serial online] 2017 [cited 2018 May 25];29:230-3. Available from: http://www.kjophthal.com/text.asp?2017/29/3/230/224302




  Introduction Top


Cysticercosis is the infestation by cysticercus cellulosae, the larval form of the pork tapeworm, Taenia solium.[1] It is contracted by ingestion of the infective cysticerci in under cooked pork; ingestion of eggs of T. solium in contaminated water, food, or vegetables; and regurgitation of eggs from the small intestine.[2] The sites for predilection for the development of cysticerci are the central nervous system, subcutaneous tissue, skeletal muscle, heart muscle, and eye.[3]

Tapeworms can cause two different human diseases, taeniasis and cysticercosis. Taeniasis is an intestinal infection caused by the adult T. solium and Taenia saginata. Cysticercosis, the most common ocular infestation in humans, is caused by encystment of the larvae (cysticercus cellulosae) of the tapeworm T. solium, in which humans are the intermediate hosts in the life cycle.[2] The ocular manifestations can be devastating as the cysticercus increases in size, leading to blindness in 3–5 years. Death of the parasite causes marked release of toxic products, leading to a profound inflammatory reaction and destruction of the eye.[4] Appropriate sanitation and personal hygiene are important in control of fecal contamination of water and food.

Prevalence

Risk factors include a family history of parasitic infestation, history of travel to an endemic area, or household visitors from an endemic area. Ocular cysticercosis is endemic in tropical areas, such as Sub-Saharan Africa, India, and East Asia. There is no specific sex predilection. People of any age may be affected although orbital cysticercosis is more commonly reported in younger age groups.[5] The most common form of systemic involvement is neurocysticercosis. Ocular and adnexal cysticercosis represents 13%–46% of systemic disease. Ocular cysticercosis can involve any part of the eye: approximately 4% involve the eyelid or orbit, 20% involve the subconjunctival space, 8% involve the anterior segment, and 68% involve the posterior segment (subretinal and intravitreal).[6] Although vitreous, subretinal, and subconjunctival cysticercosis have been reported most often, the orbit is occasionally the site of cyst lodgement.[7] In a series of ocular/adnexal cysticercosis, the most common location of cysticerci was in the vitreous in 50% of cases, orbital cysts were present in 18%, and subconjunctival cysts in 3%.[8] In another case series from India, the most common locations of cyst were in the anterior orbit in 69% of cases,[3] subconjunctival space in 24.6%, posterior orbit in 5.8%, and the eyelid in 0.6% of cases. Ocular involvement is usually unilateral, but bilateral involvement may occur in cases of disseminated cysticercosis. Left eye is more commonly involved in comparison to the right, possibly because larva may be preferentially routed to the left internal carotid artery which directly originates from the aorta; however, this has not been substantially proven. The medial side of the eye has been more commonly involved than the lateral side on account of the anatomic course of the ophthalmic artery, which after giving off the lacrimal branch runs on the medial side of the orbit before diving into the terminal branches. Infestation of the ocular adenexa is probably through the anterior ciliary artery. Parasite reaches the posterior segment through the posterior ciliary artery.[9] Extraocular myocysticercosis: cysticercosis of extraocular muscle usually presents as recurrent pain, redness, proptosis, ocular motility restriction, diplopia, and ptosis. One or more extraocular muscles may be simultaneously involved although a propensity for involvement of the superior muscle complex and the lateral rectus muscles has been reported.[10] Depending on the muscle involved, clinical findings of Duane retraction syndrome or Brown syndrome may be observed. Blepharoptosis may occur due to severe inflammation, anterior orbital cyst, or involvement of superior muscle complex.

Diagnosis

Imaging studies are the most helpful in establishing the diagnosis of cysticercosis. High-resolution ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) help in detection of the orbital cyst. Diagnosis of infection with adult T. solium is made by stool examination and finding the eggs of proglottids of the worm. B-scan ocular USG reveals a well-defined cystic lesion with clear contents and a hyperechoic area suggestive of a scolex.[11] CT scanning of the orbits is a reliable technique to help establish a diagnosis of ocular cysticercosis. The characteristic feature is a hypodense mass with a central hyperdensity suggestive of the scolex. MRI reveals a hypointense cystic lesion and hyperintense scolex within the extraocular muscle. Positive test results from a serum enzyme-linked immunosorbent assay for anticysticercal antibodies help confirm the diagnosis in cases where scolex is not visible; however, negative test results do not exclude cysticercosis. Eosinophilia is an associated good diagnostic value.

Treatment

Albendazole and praziquantel are the larvicidal drugs used in the treatment of cysticercosis in human.[12] Once the diagnosis of orbital cysticercus is confirmed, it is of utmost important to rule out intraocular and central nervous system involvement. Dying cysticercus releases its toxin and incites severe inflammatory reaction leading to vitritis and may lead to blindness. Hence, it is mandatory to check for intraocular involvement of cysticercus cyst. Albendazole is usually given at 15 mg/kg/day with a maximum of 400 mg/bid (higher doses have been given) with repeated-dosings as clinically warranted. Treatment may increase inflammation as the cyst involutes, leading to worsening clinical states. Thus, concomitant administration of corticosteroids is recommended to avert an inflammatory response. That usually occurs 2–5 days after initiation of therapy. Orbital cysts are best treated conservatively with a 4-week regimen of oral albendazole (15 mg/kg/day) in conjunction with oral steroids (1.5 mg/kg/day) in a tapering dose over a 1-month period.[13] Surgical removal of the cysticercus is the recommended treatment for subconjunctival space cysticercosis, as it gives excellent results. Serial B-scan ocular USG or CT scanning of the orbit helps follow the resolution of cyst.


  Case Report Top


A 10-year-old girl presented to us with complaints of bluish-colored swelling bellow her right upper eyelid for the last 3 months with headache. The swelling was gradually increased in size for the last 3 months. It increases in size on bending forward and decreases on lying down. There was no visual disturbances, no diplopia, no pain, no episode of seizure disorder and vomiting, no history of skin rashes, and no history of worm infestation. There was no history of convulsion or any worm infestation. On examination, visual acuity was 6/6 in both eyes and intraocular pressure was 14 mmHg in both eyes. There was no proptosis, no extraocular muscle restriction, and no redness. Anterior segment examination was normal. There was mild right upper eyelid swelling. There was a bluish-colored swelling of 3 cm × 3 cm in size beneath the right upper lid with well-defined smooth surface [Figure 1]. It was nontender and cystic in consistency [Figure 2]. The swelling was compressible. Clinically, a differential diagnosis of orbital varices and anterior orbital cysticercus was made. Fundus examination was normal. Ultrasound B-scan showed a well-defined cystic lesion bellow the conjunctiva in the superior palpebral fissure area. CT of orbit showed a well-defined hypodense cystic lesion [Figure 3] in the superior palpebral fissure area with no definite scolex within it. CT scan brain was normal. Stool examination showed eggs of worm T. solium. Complete blood count showed eosinophilia. Based on all, a diagnosis of anterior orbital cysticercus was made and put on 4-week regime of oral albendazole 15 mg/kg/day with a maximum of 400 mg/bid along with oral steroid (1.5 mg/kg/day) in a tapering dose over a 1-month period. After 1-month follow-up, there was complete resolution of that cystic lesion [Figure 4].
Figure 1: Bluish-colored swelling bellow right upper lid

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Figure 2: Non-tender and cystic in consistency

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Figure 3: CT of orbit showed a well-defined hypodense cystic lesion

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Figure 4: After 1 month follow up, there was complete resolution of that cystic lesion

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  Summary Top


Orbital cysticercosis is a common clinical condition in the developing world. It has myriad clinical presentations depending on the site of lodgment. Subconjunctival cysticercus cyst not responding to the oral treatment should be surgically removed and sent for histopathological examination. Once the infection is diagnosed, it is importance to rule out intra- and intra-cranial involvement as involuting cysticercus leads to severe inflammatory reaction which if not diagnosed and treated on time may lead to blindness. Appropriate sanitation and personal hygiene are important in control of fecal contamination of water and food. Raw and improperly cooked food should be avoided, especially in endemic area.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Odel JG, Moazami G. Diseases caused by helminths. In: Miller NR, Newman NJ, editors. Walsh and Hoyt's Clinical Neuro-Ophthalmology. Baltimore: Williams and Wilkins; 1997. p. 4439-44.  Back to cited text no. 1
    
2.
Markell EK, John DT, Krotoski WA. Medical Parasitology. 8th ed. Pennsylvania: Saunders; 1999.  Back to cited text no. 2
    
3.
Pushker N, Bajaj MS, Chandra M. Ocular and orbital cysticercosis. Acta Ophthalmol Scand 2001;79:408-13.  Back to cited text no. 3
    
4.
Reddy PS, Satyendran OM. Ocular cysticercosis. Am J Ophthalmol 1964;57:664-6.  Back to cited text no. 4
    
5.
Sen DK, Mathur RN, Thomas A. Ocular cysticercosis in India. Br J Ophthalmol 1967;51:630-2.  Back to cited text no. 5
    
6.
Atul K, Kumar TH, Mallika G, Sandip M. Socio-demographic trends in ocular cysticercosis. Acta Ophthalmol Scand 1995;73:438-41.  Back to cited text no. 6
    
7.
Bartholowmew RS. Subretinal cysticercosis. Am J Ophthalmol 1975;79:670-3.  Back to cited text no. 7
    
8.
Murthy GR, Rao AV. Sub-conjunctival cysticercosis. Indian J Ophthalmol 1980;28:77-8.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Genta RM, Connor DH. Infectious and parasitic diseases. In: Rubin E, Farber J, editors. Pathology. Philadelphia: Lippincott- Raven; 1999. p. 356-479.  Back to cited text no. 9
    
10.
Sundaram PM, Jayakumar N, Noronha V. Extraocular muscle cysticercosis – A clinical challenge to the ophthalmologists. Orbit 2004;23:255-62.  Back to cited text no. 10
    
11.
Honavar SG, Sekhar CG. Ultrasonological characteristics of extraocular cysticercosis. Orbit 1998;17:271-84.  Back to cited text no. 11
    
12.
Rath S, Honavar SG, Naik M, Anand R, Agarwal B, Krishnaiah S, et al. Orbital cysticercosis: Clinical manifestations, diagnosis, management, and outcome. Ophthalmology 2010;117:600-5.e1.  Back to cited text no. 12
    
13.
Puri P, Grover AK. Medical management of orbital myocysticercosis: A pilot study. Eye (Lond) 1998;12(Pt 5):795-9.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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