Extraocular muscle cysticercosis - a clinical challenge to the ophthalmologists

Unusual and Rare Causes of Monocular Elevation Deficit

INTRODUCTION

To study the rare and unusual causes of monocular elevation deficit.

METHODS

Five patients presenting to us with diplopia and elevation deficit were thoroughly examined and were found to have monocular elevation deficit due to rare causes.

OBSERVATIONS

All five were found to have different underlying etiologies - iatrogenic, sphenoid wing meningioma, cysticercosis, sarcoidosis and mid brain infarct, and were managed appropriately.

DISCUSSION

Monocular Elevation Deficit can occur due to a variety of causes. Having a high index of suspicion for the more serious etiologies is of utmost importance. Thorough clinical examination and imaging help clinch the diagnosis.

Bacterial pyomyositis of the extraocular muscles: case report and systematic review

OBJECTIVE

To describe the manifestations and treatment of extraocular muscle (EOM) bacterial pyomyositis.

DESIGN

A systematic review following PRISMA guidelines and a case report.

METHODS

PubMed and MEDLINE databases were searched for case reports and case series of EOM pyomyositis using the term "extraocular muscle" combined "pyomyositis" and "abscess". Patients were included as bacterial pyomyositis of the EOMs when there was a response to antibiotics alone or if a biopsy was consistent with the diagnosis. Patients were excluded when pyomyositis did not involve the EOMs or when diagnostic tests or treatment were not in keeping with the diagnosis of bacterial pyomyositis. An additional patient with bacterial myositis of the EOMs, treated locally, was added to the cases identified in the systematic review. Cases were grouped for analysis.

RESULTS

There are 15 published cases of EOM bacterial pyomyositis including the one reported in this paper. Bacterial pyomyositis of the EOMs typically affects young males and is caused by Staphylococcus species. Most patients present with ophthalmoplegia (12/15; 80%), periocular edema (11/15; 73.3%), decreased vision (9/15; 60%) and proptosis (7/15; 46.7%). Treatment involves antibiotics alone or in combination with surgical drainage.

CONCLUSIONS

Bacterial pyomyositis of the EOM presents with the same signs as orbital cellulitis. Radiographic imaging identifies a hypodense lesion with peripheral ring enhancement within the EOM. An approach to cystoid lesions of the EOMs is helpful in reaching the diagnosis. Cases can be resolved with antibiotics aimed at treating Staphylococcus, and surgical drainage may be required.

Extraocular muscle enlargement

Extraocular muscle enlargement can occur secondary to a range of orbital and systemic diseases. Although the most common cause of extraocular muscle enlargement is thyroid eye disease, a range of other inflammatory, infective, neoplastic, and vascular conditions can alter the size and shape of the extraocular muscles. Imaging with computed tomography and magnetic resonance imaging plays an essential role in the workup of these conditions. This article provides an image-rich review of the wide range of pathology that can cause enlargement of the extraocular muscles.

Case of Orbital Cysticercosis Presenting as Recurrent Cellulitis Diagnosed on Multi-Modality Imaging

Cysticercosis results in humans when infected with the larval stage of taenia solium which is called cysticercus cellulosae. The target organs usually involved are the brain, eyes, spine, and skeletal muscles. The ocular form of cysticercosis can affect the intra-ocular structures or involve the orbital adnexa. Intraocular involvement is relatively common and is readily diagnosed owing to its obvious visibility on a basic slit-lamp examination, however, affection of orbital adnexa is infrequent. Moreover, solitary involvement of one of the extraocular muscles is rare and difficult to diagnose as it presents with a spectrum of non-specific symptoms. We report a rare case of orbital cysticercosis with a solitary left superior rectus muscle involvement, who presented with recurrent on and off lid swelling extending for two years with double vision and restriction of downward gaze.

Orbital cysticercosis: clinical features and management outcomes

AIM

To describe the clinical and radiological features of orbital cysticercosis and its management outcome.

MATERIAL AND METHOD

A retrospective analysis of consecutive cases of orbital cysticercosis between January 2008 and January 2018. The management outcome was classified into good, fair, and poor depending upon the resolution of the clinical features and status of the cyst and scolex in the imaging studies.

RESULTS

A total of 61 patients with a mean age of 24.33± 31.04 years were included. The male: female ratio was 1.9:1. Pain, with or without prominence of the eye was the most common presenting symptom (n = 35, 57.4%). The mean duration of symptoms was 3.65 +/-8.56 months. Ocular motility restriction was the most common sign (n = 52, 85.2%). Fifty-five (90.16%) patients had myocysticercosis with inferior rectus being most commonly involved (n = 17, 27.9%), while 6 (9.83%) cases had orbital cysticercosis without any ocular muscle involvement. Four patients had compressive optic neuropathy. Subjectively, good clinical outcome was documented in 37 (60.65%), fair in 17 (27.87%) and poor in 7 (11.47%) patients. Objectively, imaging studies showed complete resolution of the cysticercosis lesion in 18 (45%), partial in 19 (47.5%), and no change in 3 (7.5%) patients.

CONCLUSION

A high index of suspicion and a thorough knowledge of the clinical and radiological features are necessary for the proper diagnosis and management of orbital cysticercosis. Medical management with oral albendazole combined with oral steroids leads to desired outcome in the majority.

Cysticercosis in ophthalmology

Cysticercosis is caused by Taenia solium, a cestode or tapeworm that preferentially affects the subcutaneous tissue, brain, muscle, and the eye. It is traditionally a disease of low socioeconomic regions, but large-scale population migration has made it a matter of global concern. Its ocular invasion is a potentially blinding disease. In the last two decades, there has been considerable discussion of cysticercosis; however, most comes from a limited number of case observations. Thus, to overcome this limitation, we summarize and analyse twenty years of medical literature (from 2000 to 2020) on cysticercosis in ophthalmology.

Quantitative assessment of lesion load and efficacy of 3 cycles of albendazole in disseminated cysticercosis: a prospective evaluation

BACKGROUND

The management of disseminated cysticercosis is unclear and largely considered hazardous. The role of albendazole remains controversial in such patients.

METHODS

A tertiary care, University hospital-based prospective intervention study was conducted from December 2015 to December 2017. Patients with disseminated cysticercosis, defined as the presence of multiple viable neurocysticerci (≥ 3) in the brain along with involvement of an additional extra site, were included in the study. Patients with cysticercal encephalitis were excluded. A detailed evaluation, including ophthalmoscopy, ocular B scans, ultrasound abdomen, and X-rays were done. Albendazole was administered at a dose of 15 mg/kg/day in 3 cycles of 28 days each. All patients were also given adjuvant corticosteroids and anti-epileptic drugs. Clinical and radiological follow up was carried out at a difference of 3 months between each treatment cycle. For radiological quantification, lesions were counted at 10 pre-specified levels. Statistical analysis was done to estimate the difference in seizure frequency and lesion load.

RESULTS

Twenty-nine patients (21 with > 20 lesions; 8 with ≤ 20 lesions) were given albendazole as per the protocol. There was a significant reduction in the occurrence of seizures (P < 0.001) and headache (P < 0.001). A significant reduction in lesion load from baseline to third follow-up was seen in the estimations done at different levels (P < 0.001). No patient developed serious side-effect warranting cessation of therapy.

CONCLUSION

Cyclical use of albendazole appears efficacious in treating disseminated cysticercosis. The method of quantification described may be used in future studies for objective assessment.

TRIAL REGISTRATION

ISRCTN11630542; 28th September 2019; Retrospectively registered.

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.

Surgical Excision of Orbital Cysticercosis Lodged in Superior Oblique Muscle: Clinical Case Report

Ocular cysticercosis refers to parasitic infections in humans. Most cases were treated by medicine. The case we reviewed was rarely reported with successful surgical intervention treatment.This case report describes a patient with cysticercosis existing in superior oblique tendon. The main symptom of the patient was recurring history of painless orbital swelling and double vision in upgaze. Ocular motility examination revealed a restriction of the right eye in levoelevation. A contrast-enhanced computed tomographic scan of the orbit revealed the presence of a well-defined hypodense cystic lesion within the right superior oblique muscle.The patient was diagnosed with orbital space-occupying mass with acquired Brown syndrome. Surgical exploration of the superior oblique muscle was performed, and the cyst was removed from the eye and confirmed by histopathological examination. After surgery, an ocular motility examination revealed orthotropia in the primary position and downgaze, with mild restriction in levoelevation.Surgical removal could substitute for medical therapy when the cysticercosis is lodged in the superior oblique muscle, although, prior to surgery, important factors, such as patient requirements, surgical skills of the surgeon, and cyst placement, should be considered.

Inferior rectus muscle ocular cysticercosis: A case report

Cysticercosis is a systemic parasitic disease caused by the larval form of cestode Taenia solium. It has a worldwide distribution and is potentially harmful with variable clinical manifestations. The most commonly involved sites include eye, brain, bladder wall, and heart. Ocular cysticercosis can be extraocular or intraocular and may present with varied clinical symptoms. We report the condition in a thirteen year old female child who presented with mild lower lid swelling and diplopia in upgaze, wherein cysticercus cellulosae cyst was found within the mass of the right inferior rectus muscle. It becomes important to report this case because of the relative rarity of the condition these days, unusual site of the cyst and the young age of the patient.

Imaging anatomy and pathology of extraocular muscles in adults

The extraocular muscles (EOM) are involved in a variety of disease processes with characteristic findings on imaging. EOM anatomy is described, followed by a review of adult EOM pathology. The imaging characteristics are explained with examples. The pattern of EOM disease on imaging, in corroboration with clinical findings, can often lead the radiologist towards a specific diagnosis.

Multiple brain parenchymal neurocysticercosis with extraocular muscle cysticercosis affecting levator palpebral superioris and superior rectus complex: an unusual association

An 8-year-old girl presented to the neurology department with a complaint of insidious onset of left-sided ptosis and restricted elevation of the left eye. A CT scan orbit and brain revealed a ring-enhancing lesion in the levator palpebral superioris (LPS) and superior rectus (SR) muscle complex of the left eye and left parietal and right temporal region. She was started on steroid, followed by albendazole with improvement. The LPS/SR complex is the least common site of involvement among extraocular muscles in ocular cysticercosis. Specially, with brain neurocysticercosis (NCC), it is extremely rare. We report an unusual association of multiple brain NCC with ocular cysticercosis involving LPS and SR muscle.

Role of ultrasonography and magnetic resonance imaging in the diagnosis of intramuscular cysticercosis

OBJECTIVES

Nonspecific clinical presentations often lead to misdiagnosis of focal cysticercal myositis. This report emphasizes the role of ultrasonography and magnetic resonance imaging (MRI) in the diagnosis of solitary intramuscular cysticercosis.

MATERIALS AND METHODS

Six patients with persistent post-traumatic isolated muscular swelling were treated with analgesic and antibiotics, but the swelling did not subside. Radiographs showed soft tissue swelling with no bony abnormalities. Laboratory markers were inconclusive. Ultrasonographic and magnetic resonance images (MRI) showed typical features of intramuscular cysticercosis. Clinical, radiological, and fundoscopic evaluation of brain and eyes could not isolate any cysticercosis focus in these organs. Patients were treated with 3 weeks albendazole therapy.

RESULTS

The identifying sonographic features of intramuscular cysticercosis, as evident from this case series, included an intramuscular elliptical or oval anechoic lesion with echogenic intralesional focus likely to be scolex. Magnetic resonance images showed orientation of the cyst along the direction of muscle fibers with T2W hyperintense signal and post-contrast perilesional enhancement. All patients responded to medical treatment.

CONCLUSION

Cysticercosis may manifest as isolated muscular swelling without neurological or ocular involvement. Clinicians should be aware of this clinical condition to avoid misdiagnosis. Ultrasonography and magnetic resonance imaging are good diagnostic aids to establish soft tissue cysticercosis.

Orbital cysticercosis, case report and review

Orbital cysticercosis is secondary to an infestation by cysticercus cellulosae, the larval form of Taenia solium.Orbital cysticercosis may present with a wide spectrum of clinical findings and result in significant ocular morbidity. Although traditionally thought to be only prevalent in endemic regions with poor sanitation, immigration requires even ophthalmologists practicing in industrialised counties to be aware of this masquerading condition's presentation and treatment.We report the clinical manifestation of a case of orbital cysticersosis that presented with recurrent orbital inflammation for almost a year. We also present a literature review of the different ocular manifestations, diagnostic and treatment modalities.

Extraocular muscle cysticercosis: clinical features and management outcome

BACKGROUND

Extraocular muscle cysticercosis is rare and can be classified based on the stage of evolution as viable, degenerating, and inactive. A tailored approach to therapy using a combination of albendazole and steroids has been proposed. In this study, we have evaluated the clinical features and response of "viable" extraocular muscle cysticercosis to a tailored therapy with oral albendazole and steroids.

METHODS

A retrospective review of 32 patients with viable extraocular muscle cysticercosis was performed over a 3-year period. Ultrasound examination was performed at 3 weeks and 6 weeks for resolution of the cyst and clinical signs following treatment with oral albendazole and prednisolone. The clinical presentation, ocular alignment, motility restriction, and ultrasound examination details were recorded on serial visits.

RESULTS

The mean age was 19.5 years. The most common presenting signs included limitation of ocular motility in 75%, conjunctival mass in 37.5%, diplopia in 28.1%, and proptosis in 28.1% of the patients, respectively. Ocular alignment evaluation revealed esotropia in 3.1%, exotropia in 12.5%, and hypertropia in 6.25%. Restriction of abduction and abduction in elevation was present in two patients each. The average time for complete resolution was 65.9 days. All the patients had resolution, except four, who had residual motility limitation but were asymptomatic.

CONCLUSIONS

Combination therapy with oral albendazole and steroids is effective in the management of viable extraocular muscle cysticercosis. However, residual motility restriction may persist despite treatment.

Tear IgA-ELISA: a novel and sensitive method for diagnosis of ophthalmic cysticercosis

For the first time, presence of locally secreted specific IgA antibodies in tear specimen from human with ophthalmic cysticercosis is documented in the present study. The ELISA using Taenia solium metacestode excretory secretory (ES) antigen demonstrated a diagnostic level of IgA antibodies in tears with 100% sensitivity (6 out of 6 confirmed cases of ophthalmic cysticercosis) whereas, 25 of 34 (73.52%) clinically suspected cases were diagnosed positive. The ELISA using T. solium metacestode somatic antigen detected a diagnostic titre of IgA antibody in tears with a sensitivity of 50% (3 out of 6 confirmed cases). The specificity of the tear IgAELISA using T. solium metacestode somatic and ES antigens is observed to be 94.87% and 92.3%, respectively. Overall in tears, the ELISA using T. solium metacestode ES antigens for detection of IgA antibodies shows a higher diagnostic efficiency (93.33%) compared to that using T. solium metacestode somatic antigen (88.88%). The sensitivities of the ELISA for detection of IgA antibodies in tears is observed to be higher than that for detection of IgG antibodies in serum using either somatic or ES antigens of the parasite.

Cysticercosis of the bony orbit--a rare entity

Bone involvement in cysticercosis is a rare occurrence. A case of cysticercosis of the frontal orbital bone in a thirty-year-old female is reported. The diagnosis was established by computerized tomographic scanning of the orbit and histopathological examination of the cyst, surgically removed from the cavity in the orbital plate of the frontal bone. To our knowledge, this is the first case report of cysticercosis of the bony orbit.