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|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 5 | Page : 1058-1060
Vijay Sardana1, Piyush Ojha1, Divya Sharma2, Sunil K Sharma1, Sangeeta Saxena3, Naresh N Rai4
1 Department of Neurology, Government Medical College, Kota, Rajasthan, India
2 Department of Psychiatry, Government Medical College, Kota, Rajasthan, India
3 Department of Radiodiagnosis, Government Medical College, Kota, Rajasthan, India
4 Department of Pathology, Government Medical College, Kota, Rajasthan, India
|Date of Web Publication||12-Sep-2016|
Department of Neurology, Government Medical College, Kota, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sardana V, Ojha P, Sharma D, Sharma SK, Saxena S, Rai NN. Disseminated cysticercosis. Neurol India 2016;64:1058-60
Disseminated cysticercosis (DCC) is a rare complication of cysticercosis, which is caused by Cysticercus cellulosae, the larval form of the pork tapeworm, Taenia solium. It can involve any organ of the body. We report 2 cases of DCC with diffuse involvement of the brain, subcutaneous tissue and multiple organs accompained by a diffuse muscle hypertrophy [Video 1].
The first patient, a 25-year-old male patient, non-vegetarian (with a history of pork ingestion), presented with recurrent generalized seizures and diffuse swelling of his muscles for the last 8 months. The patient was conscious and oriented, although with slow mentation and increased reaction time. Examination revealed the typical “Herculean” appearance with generalized symmetrical increase in the muscle bulk involving all extremities [Figure 1]. Multiple firm, well-circumscribed, non-tender subcutaneous nodules were present all over the body including the tongue. Magnetic resonance imaging (MRI) of the whole body revealed innumerable, tiny, ring-shaped nodular enhancing lesions involving the brain (starry sky appearance), scalp, orbits, neck, extremities and spinal cord suggestive of DCC [Figure 2]. After initiating antiepileptics, the patient remained seizure free for the next few months, following which he was admitted with symptoms and signs suggestive of raised intracranial tension, leading to coma and aspiration pneumonitis, and an eventual death.
|Figure 1: A 25 year old male patient with Disseminated Cysticercosis. The patient had a typical “Herculean” appearance with a generalized muscular pseudohypetrophy. Multiple well-circumscribed firm, non-tender subcutaneous nodules were present all over the body and even visible on the tongueDisseminated|
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|Figure 2: MRI brain and whole body of the patient (Case 1 and Figure 1) was suggestive of innumerate tiny ring shaped enhancing lesions in the whole of brain parenchyma, scalp, orbits and neck tissues suggestive of disseminated cystecercosis|
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The second patient, a 16-year-old male, vegetarian, presented with a low-grade fever, diffuse headache, and altered sensorium with multiple nodular lesions over the body for the last 2 months. There was no history of seizures. Examination revealed multiple superficial non-tender cystic lesions (1–2cm) over the chest, back, neck, all extremities, and tongue. Ultrasonography of both the orbits was suggestive of multiple well-defined ring-like hyperechoic lesions with a central hyperechoic core and a peripheral halo in the retinal area of the right eye and in the optic nerve region of the left eye, suggestive of cysticercosis. MRI of the whole body was consistent with DCC [Figure 3]. Biopsy of a subcutaneous swelling was histopathologically consistent with Cysticercus cellulosae [Figure 4] and [Figure 5]. After symptomatic management and administration of antiepileptic medication, the patient has been asymptomatic since the last 2 months.
|Figure 3: MRI Brain and whole body of Case 2 - A 16-year male presented with complaints of low grade fever, headache and altered sensorium and multiple nodular lesions over various parts of body. Magnetic resonance imaging (MRI) was suggestive of multiple hyperintense foci involving the brain, scalp, orbital muscles, tongue, neck, vertebrae, chest as well as all extremities suggestive of disseminated Cysticercosis|
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|Figure 4: Patient (Case 2 ) had multiple superficial nontender cystic lesions over the chest, back, neck, upper extremities, and tongue. Biopsy of a subcutaneous swelling taken from Left arm (picture) was histopathologically consistent with Cysticercosis Cellulosae|
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|Figure 5: Section shows branching tegument (cuticle) with aggregated subcuticular cells (Hematoxylin and eosin section, ×10)|
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Cysticercosis is a common disease seen in the tropical countries caused by Cysticerus cellulosae, which is the larval form of the pork tapeworm, Taenia solium. It commonly involves the subcutaneous tissues, skeletal muscles, lungs, brain, eyes, liver, and occasionally the heart, thyroid, and pancreas. It is caused by the consumption of eggs of the tapeworm and spreads by the feco-oral route, where humans act as intermediate hosts, due to poor sanitary conditions and contamination from the tapeworm carriers.
The commonly seen central nervous system involvement has varied clinical manifestations, which may be a consequence of inflammatory process around a cyst, the cyst acting as a space occupying lesion causing obstruction to the cerebrospinal fluid flow, and less commonly, due to meningeal or vascular inflammation.
DCC, a very rare variety of cysticercal infestation, was first reported by a British army medical officer in India in 1912. The clinical features mainly depend on the cyst location, burden, and host reaction. The common manifestations include intractable epilepsy, dementia, muscle hypertrophy, and subcutaneous and lingual nodules, with a relative absence of focal neurological signs. Muscular involvement leads to painless diffuse enlargement (pseudohypertrophy) of all muscle groups giving the patient a “Herculean appearance.” This may be associated with weakness and easy fatiguability of the muscles. Ultrasonography may reveal cystic lesions, with or without calcification, in the hypertrophied muscles. Severe pain, blurring of vision, and loss of vision are common manifestations of ocular involvement. Fundoscopic examination, ultrasonography of the eyes, and color Doppler studies are useful in diagnosing ocular cysticercosis. Neither of our patient had visual symptoms.
The MRI is superior to computed tomography (CT) scan in diagnosing this entity because it delineates the scolex and live cysts in the cisternal spaces and the ventricles, better visualizes surrounding inflammation, and helps to assess the response to treatment  whereas a CT scan is a superior radiological modality for picking up inactive calcified lesions.
The treatment is symptomatic using steroids and antiepileptics. Surgical removal of the cysts and ventriculo-peritoneal shunting may be needed in patients with raised intracranial tension, to relieve the symptoms. Cysticidal drugs, such as albendazole and praziquantel, may help by hastening the death of cysts, which may occur even in the absence of this treatment. Cysticidal therapy may be associated with a severe reaction, which may be due to cyst enlargement, massive release of antigens causing local tissue swelling, and generalized anaphylactic reaction. Hence, these therapies should be advised with high degree of caution and should be individualized. Cysticidal drugs have no role in the presence of inactive calcified cysts.
DCC involving multiple organ systems with widespread muscle hypertrophy is very rare and carries a sinister prognosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]