Extraocular muscle cysticercosis presenting as Brown syndrome

Ophthalmic presentations and long-term outcomes of subconjunctival and atypical orbital myocysticercosis

PURPOSE

To study the clinical presentation, radiological features, diagnosis, and treatment response in subconjunctival and atypical orbital myocysticercosis.

METHODS

Retrospective analysis of diagnosed subconjunctival and atypical (strabismus, diplopia, and blepharoptosis) orbital myocysticercosis was performed. A diagnostic criterion (2 of the 3) among clinical features, radiological findings, and treatment response was used in our study. A minimum of "post-treatment" follow-up of 12 months was observed.

RESULTS

Thirty-five patients were included with a mean age of 16 years having male predominance (n = 22, 62.8%). All had a unilateral presentation, with 24 (68.6%) patients having subconjunctival cysticercosis, of which 22 were located in close proximity of the rectus muscle insertion. At presentation, 10 patients had diplopia, 7 had strabismus, and 6 had face turn. Pseudo Duane's and pseudo-Brown's syndrome were noted in 5 and 4 patients, respectively. Radiologically, single muscle myositis without scolex was seen in 12 (34.3%) cases. All patients first received medical treatment, and surgical intervention (cyst removal) was attempted after treatment failure. Complete resolution of symptoms was noted in 22 (after medical treatment only) and in 8 (after surgery).

CONCLUSION

In the majority, the subconjunctival cysticercosis is found in proximity to the rectus muscle insertion, as a part of orbital myocysticercosis. In atypical scenarios, a satisfactory response to medical treatment can be considered as diagnostic of cysticercosis.

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.

Lacrimal sac cysticercosis: a rare site for manifestation

Cysticercosis, a parasitic tissue infestation caused by larval cysts (cysticercus cellulosae) of the pork tapeworm, Taenia solium, most commonly affects the central nervous system, subcutaneous tissue, skeletal muscle, heart muscle, and the eye. Ocular adnexal infestation in cysticercosis can involve various sites within the eye like vitreous humor, subretinal tissue, extraocular muscle, and lacrimal gland. In this case report, a lump slightly below and medial to inner corner of eye, surgically removed from a 21-year-old male patient, was diagnosed as case of lacrimal sac cysticercosis on histopathological examination. To our knowledge, this is the one of rare sites for manifestation of cysticercus cellulosae.

Canine tooth syndrome due to superior oblique myocysticercosis

A 13-year-old boy had right periocular pain, upgaze vertical diplopia, and lid swelling. Right extorsion and hypodense cystic swelling in the right superior oblique involving the muscle and tendon behind the trochlea existed. Oral treatment was prescribed. MRI revealed a collapsed cyst. Ocular motility improved, but levoelevation diplopia persisted.

Atypical presentations of orbital cysticercosis

We describe three patients with orbital cysticercosis who presented with atypical clinical or radiologic features previously unreported. All three patients had a cyst with a scolex on imaging studies. After 6 weeks of treatment, all three had almost complete resolution of their features.

Uniocular ptosis due to cysticercosis of extraocular muscle

Involvement of extraocular muscle by Cysticercus cellulosae is very rare. Rarer still is the isolated involvement of the levator palpebrae superioris muscle presenting clinically as ptosis. We report here such a presentation in an eleven years old girl.

Albendazole: a broad spectrum anthelminthic for treatment of individuals and populations

PURPOSE OF REVIEW

It is over 25 years ago since the original animal research was conducted into albendazole. This review highlights some important steps in fundamental research and the management of helminth disease that have occurred in the past year, appearing in the published literature.

RECENT FINDINGS

In recent years there have been several published studies on lymphatic filariasis and on the impact of albendazole treatment on growth and nutrition. Recent work consolidates some of these data and supplies substantive evidence of benefit especially in the area of hookworm anaemia. Why treatment of helminths actually produces these effects has not been understood, but investigations have begun to highlight the underlying mechanisms that relate to immunity. During the last year several reviews of diagnosis and management of helminth diseases have been published which provide much needed guidance on the effective use of albendazole, and its place in treatment overall. In common with many other parasitic diseases, the validity of using single agents is being challenged, and combination therapy is being investigated at the experimental level and in clinical practice to improve therapeutic responses and to reduce the risk of resistance to the limited range of drugs currently available.

SUMMARY

Albendazole has changed from being a drug for individuals with worms to one to treat communities and provide benefit in public health terms. In systemic parasitic disease, however, albendazole remains a treatment for individuals. Nearly 20 years of research and of clinical use has refined the tool, but new investigations suggest that much additional study is required before we fully understand helminth parasites and the benefits of treating them.

Orbital and adnexal cysticercosis

Orbital and adnexal cysticercosis is emerging as a far commoner disease than previously considered, both in endemic and nonendemic areas of cysticercosis. A review of the literature on orbital and adnexal cysticercosis found that it has a predilection for children and young adults with no definite sex predilection. The extraocular muscle form is the commonest type of orbital and adnexal cysticercosis. Lodgement of cysts in the subconjunctival space is another common site, followed by the eyelid, optic nerve, retro-orbital space and lacrimal gland. Association of orbital cysticercosis with systemic cysticercosis is quite rare. The clinical manifestations of orbital or adnexal cysticercosis are entirely different and depend on the location, size, relation to adjacent structures and stage of evolution of the cyst. Diagnosis of cysticercosis is based mainly on orbital imaging because of its highly specific appearance. Tissue diagnosis is not essential for initiating treatment. Medical therapy is the recommended treatment for the extraocular muscle form and retro-orbital cysticer-cosis. Surgical removal is advocated for subconjunctival and eyelid cysticercosis. Because of the limited number of cases of optic nerve and lacrimal gland cysticercosis, their treatment is controversial.