Histopathologic examination revealed the cystic mass to be Cysticercus cellulosae , the larval form of Taenia solium. This patient had been in Vietnam and Laos several years previously and, while there, developed a flu-like syndrome. Despite the fact that she was asymptomatic for the two years preceding her clinical examination, the histopathologic diagnosis of C cellulosae prompted an extensive medical and neurologic work-up to rule out the possibility that the patient harbored the adult tapeworm or other larval forms. Fortunately, the results of this survey were negative. Cysticercosis of the Eyelid. Arch Ophthalmol.
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Novel Aspects on Cysticercosis and Neurocysticercosis. Cysticercosis is a disease closely related to poverty in general and in particular with a poor personal hygiene and food, socio-cultural factors, environmental, education for health in the community, and also very closely related to the hygienic and sanitary conditions of each region.
This is a preventable and an eradicable disease [ 1 ] that currently affects more than 50 million people in the entire world, of which thousand live in Latin America [ 2 ] is internationally accepted that the onset of epilepsy, intracranial hypertension or headache of unknown cause in a person originating, visitor or in contact with another person from an area where T solium is endemic suggests considering the diagnosis of NCC. The patient affected by the NCC can remain asymptomatic for several months or years, and its diagnosis can be confirmed by accident when a CT scan is carried out in search of another diagnosis.
When the parasite is an adult expels its mature proglotides and eggs with the stool to the environment; the subsequent ingestion of these eggs of pork cause porcine cysticercosis PCC. When a person swallows raw pork meat or not well cooked and infected with cysticerci CT then develops a new adult parasite. The human then becomes an accidental intermediate host. These oncosphere primary larvae penetrate the intestinal mucosa and enter the circulatory system.
The Hematogenous spread of neural, muscular, and ocular tissues occurs. Within these tissues, the oncosphere develop into secondary larvae i. When man eats the eggs of T. See Chapter 3 [ 6 - 32 ] As has been mentioned, the location of Ct larval stage in the CNS and the eye considering the retina as an extension of the CNS is called NCC and is considered the neurological disease more important of parasitic origin in man and the main cause of epilepsy late onset.
WHO includes the NCC between neglected diseases or forgotten that cause a significant impact on the economy in several regions of the world. Islam was not the first religion to prohibit the consumption of pork, before that Judaism made it perhaps less severe restrictions; however some cases have been reported in the Jewish community in New York. Due to globalization a growing number of uncontrolled migrants from endemic areas of Latin America came to the USA every day therefore a significantly increasing number of cases of NCC are gradually diagnosed in the country, especially in the southwest, including Texas and California.
In , Pawlowski [ 43 ] stipulated that in the world would have 2. In his recent book, Hotez [ 2 ] reported that in the United States were confirmed between one and two thousand cases of NCC each year and considering the growing Latino population could have more than 41, Hispanics suffer from NCC in that country. In Spain the growing strength of the migration of individuals coming from endemic areas has conditioned an increase in the frequency of this entity.
Some authors report a list of frequencies for these locations and some combinations among of them such as: IpNCC In Brazil, the prevalence in autopsies varies from 0. The orbits are two bony cavities occupied by the eyes and associated muscles, nerves, blood vessels, fat, and much of the lacrimal apparatus. Each orbit is shaped like a pear or a four-sided pyramid, with its apex situated posteriorly and its base anteriorly. The orbit is related to its superior side to the anterior cranial fossa and usually to the frontal sinus, laterally to the temporal fossa in anterior and to the middle cranial fossa posterior , on its inferior side of the maxillary sinus, and medially to the ethmoid bone and the anterior extent of the sphenoid sinus.
Orbital cysticercosis is caused by the infestation of the larval form of the pork tapeworm Taenia solium in the orbital cavity affecting the eyeball ocular cysticercosis or the extra ocular structures found within the orbital cavity such as: extra ocular muscles, nerves, ganglions, and fatty tissue.
Orbital cysticercosis may cause significant visual loss, especially if the cyst is located intraocularly or is compressing the optic nerve. Ocular cysticercosis may be extraocular in the sub-conjunctival or orbital tissues or intraocular in the vitreous, sub-retinal space, or anterior chamber. While either eye may be affected, bilateral involvement is rare [ 74 ] and multiple cysts may develop in the same eye.
The cysticercus may lead to blindness in years. Some authors consider that intraocular cysticercosis is predominant in the Western countries, whereas extraocular is more common in the Indian population attributed to geographic and environmental factors. Orbital cysticercosis should be suspected in patients who have lived in an endemic area and who develop uveitis, leucocoria or Neuro-Ophthalmological signs, also in the presence of sub conjunctival cysts or lids nodules.
Treatment may increase inflammation as the cyst involutes, leading to worsening clinical status. Thus, concomitant administration of corticosteroids is recommended to avert an inflammatory response. In , Rath et al. It may be, therefore our readership should remember that renal cell carcinoma RCC is a tumor of middle-aged men that metastasizes to the lung, liver, and bone.
When this tumor spreads to the orbit, the orbital metastasis is likely to be the first indication of the cancer and up to only a few cases were reported. Konya et al [ ] reported two cases: a 44 and years-old- male patients with proptosis and a tongue tumor due to RCC.
Another patient was: year-old black man with sickle cell trait, presented with a rapidly progressive painful proptosis of the left eye due to metastasis from renal medullary carcinoma.
The next report came from India. It was a year-old male who presented with pulsatile proptosis owing to metastasis of an asymptomatic renal cell carcinoma [ ] this case was an example of the great challenger. In , another three patients: two males of 67 and 58 years old males and a years-old-female from India presenting iris mass, orbital metastasis were reported.
This report suggested that patients presenting with atypical orbital or ocular masses, the possibility of renal cell carcinoma metastasis should be considered, especially if there is a history of previous renal disorder.
Incisional biopsy with histopathological evaluation may be an important means to diagnose this condition and facilitate appropriate therapy. Other author reported similar findings. Patients with hepatic cell carcinoma presenting primary symptoms of metastatic disease are rare and the retro-orbital mass as the initial manifestation of disease is also very uncommon as well. Proptosis is the most common presenting feature in the reviewed reports and a majority of patients have occult primary tumors at presentation and the diagnosis of the orbital mass is based on histopathology.
The age of the patients, clinical features of the orbital lesion, presence of other metastatic lesions, epidemiological features of cysticercosis, CT scans, and ultrasonographic studies are elements that allow you to make a certain diagnosis. In the previous chapter we reviewed some aspects on orbital cysticercosis according to their different locations within and outside of the eyeball without exceeding the limits of orbit, mainly those clinical features of the ocular cysticercosis associated with damage of other organs as part of the disseminated cysticercosis at the same time.
It may be asymptomatic in the early stages. As the parasite grows, it causes a painless, progressive loss of vision related to the area of location. Intraocular lesions caused by cysticercosis most commonly occur in the vitreous or subretinal space, but subchoroidal, sub hyaliod, and into the anterior chamber, also occur. A cyst in the anterior chamber can be manifested as an acute anterior uveitis, sometimes is so severe that is difficult to differentiate a cyst from a dislocated lens and always there is a cataract formation.
The parasite can be seen moving freely into the cavity. See figure 1. When the parasite is freely mobile it may contribute to the absence of reaction in the anterior chamber. The portal of entry of the parasite into the anterior chamber has not been well documented although some author refers that the cyst may enter the anterior chamber either from the posterior ciliary arteries or from the angle. In the posterior segment, parasites gain access presumably through the posterior ciliary arteries.
From this location, they usually pass through a rent in the retina into the vitreous. In rare cases the parasite may pass from the vitreous, through the pupil, into the anterior chamber. Infestation of the ocular adnexa is probably through the anterior ciliary arteries. The intraocular location of the cyst can cause retinal detachment, macular scarring, retinal vasculitis and vitritis [ ] and usually affects young patients unilaterally.
The cyst may be in either the vitreous cavity or the sub retinal space, and visual acuity at presentation is often poor. Most patients presenting intraocular cysticercosis can tolerate it well while the cysticercus is alive, however when the parasite dies, there is a marked inflammatory response to toxic products released from the cyst, and the patient presents a blind painful eye.
Only a few cases about cysticercosis resulting in glaucoma due to pupillary block have been reported. It can be recognized through clear media, the translucent cyst with a dense white spot formed by the invaginated scolex and the undulating movements are typical. We can see the scolex returning rapidly to the cyst when exposed to the ophthalmoscope or slit lamp light. ELISA IgG serology test for cysticercosis and Western blot contribute to confirm the diagnosis although some cross reaction can be found in patients presenting Diphyllobothriosis, Taeniasis, Cysticercosis, Echinococcosis Hydatidosis , Coenuriosis or Sparganosis.
Are of limited value in diagnosing intraocular cysticercosis. In ocular cysticercosis, serologic tests are helpful if positive, but false-negative tests may be reported, and their negativity does not rule out the disease. Fluorescein Angiography is useful in delineating the sub-retinal cyst located in the periphery of the retina.
Plain X-rays of soft tissue or skull often reveal calcified cysticerci. The enhanced CT scan is valuable for identifying and following the evolution of orbital cysticercosis, which may appear as solid, cystic or calcified nodules. MRI provides detailed images of living and degenerating cysticerci. Ultrasonography is an effective and economical alternative to MRI and CT for the detection of the intra-ocular cysticerci.
It is a real time, dynamic examination, also allows direct visualization of the movements of the parasite when it is intraocular. This appearance was consistent and reproducible, regardless of whether the cyst was intraocular or extraocular in location.
Serial B-scan ocular ultrasonography or CT scans of the orbit helps to follow the resolution of the cyst, which is recognized by the disappearance of the scolex.
Optical Coherence Tomography OCT exam is seen as hyporeflective area due to the presence of fluid in the cyst cavity.
Sometimes the height of the cyst obscured the visualization of the scolex. In children, intraocular cysticercosis can simulate retinoblastoma mainly in the inflammatory response. Medical treatment for intraocular cysticercosis is not advisable while that Albendazole or Praziquantel PZQ , in conjunction with corticosteroids can be used for extraocular presentations with very good results. Surgical treatment is used to remove the cysts from the adnexa, anterior and posterior segment.
Removal of the cyst is mandatory to remove the source of the toxins causing inflammation and early removal has been advocated by many authors. Freely mobile live cysticercus in the anterior chamber associated to NCC in patients complete asymptomatic has been reported in the medical literature. Most of studies done in India and Western countries confirmed that orbital cysticercosis with ocular involvement is an uncommon pathological process that may cause severe damage of the eyes and an important involvement of the visual acuity.
Almost always these tests were positive in cases of systemic cysticercosis in our region. This experience was confirmed also by other.
All patients came from rural areas, a reflection on the low standards of hygiene. At that time, adolescent females ingested tapeworm eggs for slimming purposes, but none of this report was under that category. From their review of the medical literature they found that up to , 1 cases of ocular cysticercosis were reported and when studied their patients most of them were occasional and came to South Africa from India.
Of the 13 patients with ocular cysts nine were found in the vitreous, three in the anterior chamber and one under the conjunctiva of the eye. The majority of patients were female and all were Zulus living in areas of KwaZulu Natal, most of them complained of loss of vision for an average of 3 months.. The only exception was one patient with the sub-conjunctival cyst who had waited 2 years before seeking treatment, since the lump had not affected his vision.
Today all types of cysticercosis in KwaZulu Natal practically disappeared and patients with cysticercosis can be seen only at the former Transkei or another province but emigrated from this region currently region C and D of the Eastern Cape Province which does not mean that cysticercosis is going to disappear in the next decade how we explained in the previous chapter. The vision was reduced in all patients to where hand movements could not be seen or to perception of light being absent or to complete blindness, except for the patient with the subconjunctival cyst.
In this series of patients because of the severity of the lesions, surgical removal, although partly successful, did not improve vision and the distribution of the cysts in the various structures of the eye was similar to cases reported in the literature.
Removal of vitreous cysts by pars plana vitrectomy is the method of choice. Removal of a cyst from the anterior chamber is relatively simple excepting cases pre-existing vitreoretinal-uveal reaction. The different modalities used to remove the cyst include paracentesis, extraction with capsule forceps, cryo-extraction, diathermia, and viscoexpression.
In individuals with uveitis, the perioperative corticosteroid administration is recommended.
Cysticercosis of the Eyelid
Novel Aspects on Cysticercosis and Neurocysticercosis. Cysticercosis is a disease closely related to poverty in general and in particular with a poor personal hygiene and food, socio-cultural factors, environmental, education for health in the community, and also very closely related to the hygienic and sanitary conditions of each region. This is a preventable and an eradicable disease [ 1 ] that currently affects more than 50 million people in the entire world, of which thousand live in Latin America [ 2 ] is internationally accepted that the onset of epilepsy, intracranial hypertension or headache of unknown cause in a person originating, visitor or in contact with another person from an area where T solium is endemic suggests considering the diagnosis of NCC. The patient affected by the NCC can remain asymptomatic for several months or years, and its diagnosis can be confirmed by accident when a CT scan is carried out in search of another diagnosis.
Cysticercosis of the eye
Cysticercosis is a preventable and eradicable cause of blindness endemic in the Indian subcontinent, South-East Asia and other developing countries. Ocular and orbital cysticercosis has varied presentations depending upon the site of involvement, number of lesion and the host immune response. In this article we present a review of the various clinical manifestations, diagnosis and management protocol for orbital and ocular cysticercosis. Owing to its varied presentation, cysticercosis may pose a diagnostic challenge to the health professionals. Early diagnosis and management can prevent the vision loss and optimize visual outcomes. Cysticercosis is a preventable cause of blindness endemic in India .
Cysticercosis of the Eye
Infect Dis Clin North Am. American Academic Ophthalmology. Intraocular inflammation and Uveitis. The eye. MD association. Base Clinical Scienci Course. Epidemiology and control of cysticercosis in Peru.