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| LETTER TO EDITOR |
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| Year : 2013 | Volume
: 61
| Issue : 6 | Page : 665-667 |
Extraocular muscle cysticercosis mimicking as pseudotumor orbit: A clinical dilemma
Vikas Chaudhary1, Shahina Bano2, Pranjali R Parmar1, Nidhi Bidasaria3, Seema Bajaj3
1 Department of Radiodiagnosis, Employees' State Insurance Corporation Model Hospital, Gurgaon, Haryana, India
2 Department of Radiodiagnosis, Lady Hardinge Medical College and Associated Smt. Sucheta Kriplani and Kalawati Hospitals, New Delhi, India
3 Department of Ophthalmology, Employees' State Insurance Corporation Model Hospital, Gurgaon, Haryana, India
| Date of Submission | 27-Oct-2013 |
| Date of Decision | 28-Oct-2013 |
| Date of Acceptance | 04-Dec-2013 |
| Date of Web Publication | 20-Jan-2014 |
Correspondence Address:
Vikas Chaudhary
Department of Radiodiagnosis, Employees' State Insurance Corporation Model Hospital, Gurgaon, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.125287
How to cite this article:
Chaudhary V, Bano S, Parmar PR, Bidasaria N, Bajaj S. Extraocular muscle cysticercosis mimicking as pseudotumor orbit: A clinical dilemma. Neurol India 2013;61:665-7 |
Sir,
In India, 78% of the cases of ocular cysticercosis have been reported from Andhra Pradesh and Puducherry. [1] Extraocular orbital cysticercosis is very uncommon, despite the frequency of ocular and brain involvement. [2] Sometimes, as in our case, it is very difficult to differentiate extraocular muscle cysticercosis from orbital pseudotumor.
A 7-year-old female child presented with 2-month complaints of right sided headache, periocular pain and redness of eye. The onset was insidious with gradual progression. The pain was aggravated by movement of the eyeball. Lateral ocular movement was restricted. Examination revealed right sided conjunctival congestion and chemosis and inflammatory swelling of right lower lid [Figure 1]. Laboratory investigations revealed raised erythrocyte sedimentation rate (54 mm at the end of 1 h) and peripheral eosinophilia (800 cells/cubic mm). Serology test (ELISA) for anti-cysticercal antibodies (IgG) was positive. B-scan ocular ultrasonography of right eye revealed a well-defined cystic lesion with an eccentric mural nodule. Pericystic soft-tissue inflammation and edema was also seen. Right lateral rectus muscle was not delineated separately [Figure 2]. Magnetic resonance imaging orbit revealed fusiform enlargement of right lateral rectus muscle. The expanded muscle contained a sharply circumscribed cyst with a small mural nodule. The inflamed extraocular muscle and the adjacent soft-tissue together produced an inflammatory pseudomass indenting the posterolateral aspect of right globe. The inflammatory changes were best observed on fat-suppressed T2-weighted image. On diffusion-weighted image, pericystic tissue showed multiple areas of reduced diffusivity suggesting inflammatory mass with abscess formation; the cyst per se did not show diffusion restriction. There was no involvement of brain parenchyma [Figure 3]. Based on imaging findings, radiological diagnosis of extraocular orbital cysticercosis of right lateral rectus muscle with formation of inflammatory pseudomass was suggested. Patient was started on systemic steroids and albendazole and was given for 6 weeks. On the 3 rd day, patient started showing improvement. Pain and fever subsided and ocular motility improved. Serial B-scan ocular ultrasonography demonstrated complete resolution of the cyst and inflammatory mass over a period of 6 weeks. | Figure 1: Clinical photograph of a 7 - year - old female child shows right conjunctival chemosis and congestion, and lower lid inflammatory swelling predominantly involving the lateral half of the right eyelid
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 | Figure 2: B - scan ocular ultrasonography of right eye reveals a well - defined cystic lesion with clear content (arrowheads) and a highly reflective pinhead lesion within it representing the scolex (thin arrow). Pericystic soft tissue inflammation and edema present (asterisk). Right lateral rectus muscle could not be delineated separately
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 | Figure 3: (a) Magnetic resonance imaging orbit of the same child reveals fusiform enlargement of right lateral rectus muscle (asterisk). The expanded muscle contains a sharply circumscribed cyst with a small mural nodule (thin arrow). (b) The inflamed extraocular muscle (its tendinous insertion) and the adjacent soft-tissue together form an inflammatory mass that mimics a pseudotumor (asterisk). (c) Pseudomass indents the posterolateral aspect of right globe (thick black arrow), slight buckling of optic nerve is observed which otherwise appears normal in morphology and signal intensity (thick white arrow). (a and b) The inflammatory changes are best observed on fat-suppressed T2-weighted images. (d) On diffusion-weighted image, pericystic tissue shows multiple areas of reduced diffusivity suggesting inflammatory mass with abscess formation; the cyst per se shows no diffusion restriction (arrowheads)
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Extraocular orbital cysticercosis most commonly involves superior muscle complex and medial/lateral recti and it usually presents with clinical features suggesting subacute orbital myositis (an inflammation of mainly the extraocular muscles). [3] A high index of suspicion is required for diagnosis of extraocular cysticercosis in areas where the disease is endemic. Imaging studies are most helpful in establishing the diagnosis. Live cysts have typical imaging appearance and are identified as well-circumscribed, spherical, non-enhancing fluid-filled structure with a mural nodule (corresponding to the invaginated protoscolex). The mural nodule may be round or elongated and curved and usually eccentric in location due to its attachment to one of the cyst wall. If larva is alive, the cystic fluid appears clear and resembles cerebrospinal fluid and vitreous in computed tomography density and magnetic resonance signal intensity. Parasite death incites a host immune response and pericystic inflammatory reaction characterized by variable degree of edema around the cyst and intense cyst wall enhancement. After parasitic death, turbidity and gelling of the fluid reduces the contrast between the nodule and the cystic fluid. Swelling and enhancement of extraocular muscle is seen in extraocular muscle cysticercosis. Inflammation of extraocular muscle and the adjacent soft-tissue may lead to the formation of an inflammatory mass that may mimic a pseudotumor. Inflammatory changes are best observed on fat-suppressed T2-weighted and contrast-enhanced image. Usually, a solitary cyst with a central scolex is observed. The scolex may not be visible if the cyst is dead or ruptured. A degenerating cyst shows variable imaging characteristic of mural nodule and the cystic fluid. Over a variable period, the disintegrating larva evolves into a granulomatous abscess and eventually a mineralized nodule. Concurrent neuro-cysticercosis may be present and should be excluded. [4],[5],[6] A combination of oral albendazole (cysticidal drug) and corticosteroid (prednisolone) is given in confirmed cases; excisional biopsy is reserved for refractory cases. [1]
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| 1. | Kaliaperumal S, Rao VA, Parija SC. Cysticercosis of the eye in South India-A case series. Indian J Med Microbiol 2005;23:227-30. 
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| 2. | DiLoreto DA, Kennedy RA, Neigel JM, Rootman J. Infestation of extraocular muscle by Cysticercus cellulosae. Br J Ophthalmol 1990;74:751-2.
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| 3. | Sundaram PM, Jayakumar N, Noronha V. Extraocular muscle cysticercosis-A clinical challenge to the ophthalmologists. Orbit 2004;23:255-62.
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| 4. | Rahalkar MD, Shetty DD, Kelkar AB, Kelkar AA, Kinare AS, Ambardekar ST. The many faces of cysticercosis. Clin Radiol 2000;55:668-74.
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| 5. | Angotti-Neto H, Gonçalves AC, Moura FC, Monteiro ML. Extraocular muscle cysticercosis mimicking idiopathic orbital inflammation: Case report. Arq Bras Oftalmol 2007;70:537-9.
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| 6. | Lotz J, Hewlett R, Alheit B, Bowen R. Neurocysticercosis: Correlative pathomorphology and MR imaging. Neuroradiology 1988;30:35-41.
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[Figure 1], [Figure 2], [Figure 3]
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