Dear Sir, We read in great interest and curiosity the various clinical presentations of cysticercosis manifesting in the ocular muscles, [1] disseminated in the skeletal muscles [2] and also presenting exclusively in the liver and skeletal muscles without Neural involvement. [3] We would like to share a case of neurocysticercosis in a mentally challenged patient who had concomitant cysticerci in the skeletal and tongue muscles strikingly noticed on the magnetic resonance imaging (MRI) of the brain. The 21-year-old male patient, known case of Down syndrome, presented with the history of two episodes of seizures. There was a brief loss of consciousness for 4-5 min after the second episode. There was no history of trauma or long-term medications and any significant history or family history of seizures. On examination, patient was disoriented. The vitals were within the normal limits. Patient had papilledema without any other significant ocular findings were noted. Patient was referred for contrast enhanced MRI to evaluate for the cause of seizures. MRI with Gadolinium contrast was done in 1.5T MRI machine (MAGNETOM Avanto1.5 Tesla MRI system, Siemens Healthcare, Germany), which showed various stages of neurocysticercosis involving neroparenchyma and tongue and cervical muscles [Figure 1]. T1 hypointense and T2 hyperintense foci were seen in the neuroparenchyma with a central dot confirming Neurocysticercosis. Some of the cysts showed edema in the surrounding parenchyma and some did not. Few showed thick enhancement and others did not. Similar lesions were seen in the tongue and cervical muscles.
As detailed in the case reports published [1],[2],[3] Neurocysticercosis is an infection of the brain parenchyma caused by the pork tapeworm “Taenia solium” via feco-oral contamination. Infection is caused by encysted tapeworm larvae within the body. Ingested eggs hatch into embryos that pass into the bloodstream crossing the intestinal mucosa and disseminate to various organs and form the larval cysts. Time duration taken for the formation of larval cysts is approximately 3 months. [4] Pigs are common intermediate hosts. However humans also act as intermediate hosts. Humans act as definitive hosts. Cysts are protected from the host’s immune response by the blood-brain barrier hence no inflammatory response is noted as long as the cyst wall (rich in glycoproteins) remains intact. [5] Because cysticerci can be found anywhere in the body (most commonly in the brain and the skeletal muscles), their location and size determine the clinical presentation. [6],[7] Common clinical manifestations of neurocysticercosis include epilepsy, cognitive dysfunction, symptoms of raised intracranial pressure, focal neurologic deficits, ataxia, and psychiatric disorders. [7] Although cysticercosis involving different organ tissues has been described previously in a few case reports, case involving the maxillofacial region including tongue muscles concomitantly with neural involvement has been rarely reported. Literature review has mentioned only 34 cases of lingual cysticercosis until date. [8] This case is an example of one of those rare cases, which involved neuroparenchyma, as well as tongue musculature and neck muscles indicating disseminated form of cysticercosis infestation detected on MRI imaging. There are five stages of the cyst, which can be recognized on imaging. [9]
Out of these five stages, only vesicular and colloidal vesicular stages were recognized in our case. Screening for the rest of the organ involvement could not be undertaken in this case as the patient was in respiratory distress and mentally challenged. Our patient was treated with albendazole with the same regimen as for neurocysticercosis and was asymptomatic at 6 months follow-up. In conclusion, cysticercosis is known to affect different tissues within the human body, e.g., eye, skeletal muscles, neuroparenchyma etc. Disseminated form of infection involving various organs simultaneously is rare and little literature is known about it. Involvement of tongue muscles is known to be rare although it is skeletal muscle. Magnetic resonance is the imaging modality of choice. [10] In suspected cases or proven cases of neurocysticercosis, other organs involvement like tongue, and cervical neck muscles (as in this case) should be looked for, which gives better idea regarding severity of involvement and dissemination of this parasitic infection. Accordingly treatment can be instituted as this is a completely curable parasitic infection and reduces further complications.
Source of Support: None, Conflict of Interest: None
[Figure 1] |
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