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| CASE REPORT |
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| Year : 2015 | Volume
: 8
| Issue : 2 | Page : 210-212 |
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Bilateral proptosis as a rare manifestation of neurocysticercosis
Akhilesh K Singh, Prabhat K Agrwal, Juned Ahmad, Ashish Gautam
Department of Medicine, S. N. Medical College, Agra, Uttar Pradesh, India
| Date of Web Publication | 13-Mar-2015 |
Correspondence Address:
Juned Ahmad
Flat No. 106, Maruti Residency, Maruti Estate, Agra, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0975-2870.153165
Cysticercosis is the most common parasitic disease of the central nervous system. Although seizure is the most common presenting feature, the presentation depends upon the location of the cysts. The other sites of involvement of cysticerci are soft tissue and eye. Unusual location of the cysts may result in uncommon manifestations. Ocular cysticercosis can involve both the intraocular and extra ocular muscle. Extra ocular muscle cysticercosis is rare. Cysticercosis rarely presents as proptosis. Orbital cysticercosis presents with limitations of ocular motility in 75% of patients. We report a case of disseminated cysticercosis presenting as bilateral proptosis. Keywords: Cysticercosis, extraoccular muscles, proptosis
How to cite this article:
Singh AK, Agrwal PK, Ahmad J, Gautam A. Bilateral proptosis as a rare manifestation of neurocysticercosis. Med J DY Patil Univ 2015;8:210-2 |
| Introduction | |  |
Cysticercosis is caused by larval stage of pork tape worm, Taenia solium. Systemic involvement is commonly seen as neurocysticercosis which presents as a space occupying intracranial lesion. Proptosis is a rare presentation of cysticercosis. We describe a case of disseminated cysticercosis presenting as bilateral proptosis.
| Case Report | | |
A 30-year-old vegetarian female, developed headache and two episodes of generalized tonic-clonic seizures 20 days back. Seizures were control on carbamazepine. Ten days later she developed protrusion of both eyes. There was no history of redness, diminution of vision and diplopia. There was no history of fever, headache, and vomiting.
Examination revealed proptosis of both eyes, pupillary reaction and ocular movements were normal. The neurological and systemic examinations were normal.
Hemoglobin and blood counts were normal, erythrocyte sedimentation rate was 10 mm. Liver function test and kidney function test was normal. Free triiodothyronine, free thyroxine, thyroid stimulating hormone was within normal limit. Lumbar puncture showed normal cells with normal protein and sugar. Computed tomography (CT) scan head and orbit revealed multiple neurocysticercosis in bilateral cerebral hemispheres with multiple cysticerci in bilateral extra ocular muscles with proptosis of both eyes [Figure 1]. Magnetic resonance imaging (MRI) of brain and orbit confirmed the same findings as in CT scan.
Patient was put on prednisolone 1 mg/kg along with albendazole at the dose of 15 mg/kg/day for 2 weeks. Steroid was continued for 2 weeks after albendazole therapy and then steroid tapered. Anti-epileptic was continued. Proptosis improved and repeats CT scan at 3 months interval showed decrease in the size of lesions of brain and extraocular muscles. | Figure 1: Computed tomography scan showing B/L neurocysticercosis in orbit and multiple cysticerci in the brain
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| Discussion | | |
Unilateral proptosis is always a greater concern than bilateral proptosis because of the fear of malignancy. [1] Having stated that, bilateral proptosis when presents has a vast differential diagnosis which requires in-depth knowledge regarding the common causes, as well as the uncommon causes [2] (like cysticercosis) for the better management of the patient.
The most common cause of bilateral proptosis is Graves' disease, [1] which causes inflammatory swelling of extraocular muscles and orbital fat, therefore, a history and physical examination pertaining to this disease should always be conducted. Other causes are infectious disorders (aspergillosis, disseminated mucormycosis); inflammatory disorders (Wegener's granulomatosis, Hand-Schuller-Christian Syndrome); storage disorders (eosinophilic granuloma); neoplastic disorders; congenital developmental disorders, genetic disorders, etc.
Regarding cysticersosis being a cause of bilateral proptosis, a study showed involvement of the eye in 3% of patients, while brain was involved in most of the cases making cysticercosis the commonest cause of epilepsy in young adults in endemics areas. [3] Cysticercosis can have varied presentations while affecting the eye, one of them is by causing ptosis, which has been reported in the literature. There are reports of midbrain neurocysticercosis causing sudden onset ptosis. [4],[5],[6] There are also reports of ptosis developing following involvement of the extraocular muscles. [6],[7],[8]
Cysticercosis usually affects highly vascularized tissues such as the brain, the masticatory muscles, the tongue and the heart [9],[10] and infects the orbit and adnexa at 5-8.4% of all ophthalmic cases. [11],[12] It is most commonly found in the extraocular muscles [13],[14] leading to restricted eye movements and inflammatory signs. [10]
Computed tomography scan was done in this patient for detecting the cyst with scolex. Higher resolution scans with 1 mm cuts [15] and spiral CT scans with image reconstruction could be used for better visualization of scolex. A study done on a comparison of imaging techniques in myocysticercosis has shown almost comparable results of ultrasound (B-scan) and CT scan, with the former being slightly better for detecting scolex. [14] There are reports that MRI can pick up the scolex better than the CT scan, MRI imaging is better than CT to evaluate neurocysticercosis because of its ability to detect the signs of cyst degeneration and pericystic inflammation. [16] It is important to have CT scan of the head done to rule out cysts in the brain before starting cysticidal drugs.
Literature regarding treatment of orbital cysticercosis is controversial. Lesions may undergo resolution spontaneously or with treatment. Cysticidal medication can produce an inflammatory response around cysticerci. Hence, therapy should be individualized on the basis of location of the lesion and activity of the disease. Combination of oral albendazole (15 mg/kg) and steroid (prednisolone 1 mg/kg) may give good results in selected cases with provision there is no threat to vision. [15],[17] In our case, patient was given combined steroid and albendazole therapy by which proptosis regressed.
| References | | |
| 1. | |
| 2. | Sekhar GC, Lemke BN, Singh SK. Cystic lesions of the extraocular muscles. Ophthal Plast Reconstr Surg 1996;12:199-205.  |
| 3. | Acha PN, Aguilar FJ. Studies on cysticercosis in Central America and Panama. Am J Trop Med Hyg 1964;13:48-53. |
| 4. | Kamali NI, Huda MF, Srivastava VK. Ocular cysticercosis causing isolated ptosis: A rare presentation. Ann Trop Med Public Health 2013;6:303-5.  |
| 5. | Singhi P, Mahajan V, Khandelwal NK. Sudden-onset ptosis caused by midbrain neurocysticercosis in 2 children. J Child Neurol 2008;23:334-7. |
| 6. | Taksande B, Jajoo U, Yelwatkar S, Ashish J. Unusual presentation of orbital cysticercosis-ptosis, diminution of vision and medial rectus weakness: a case report. Cases J 2009;2:7025. |
| 7. | Sundarka M. Bilateral ptosis due to neurocysticercosis in the midbrain. Nepal J Neurosci 2005;2:137. |
| 8. | Kaliaperumal S, Rao VA, Parija SC. Cysticercosis of the eye in South India - a case series. Indian J Med Microbiol 2005;23:227-30. [ PUBMED] |
| 9. | Wadia NH. Neurocysticercosis. In: Neurological Practice: An Indian Perspective. Wadia NH (ed). Reed Elsevier India Pvt Ltd. New Delhi 2005; p. 215-51. |
| 10. | Pushker N, Bajaj MS, Chandra M, Neena. Ocular and orbital cysticercosis. Acta Ophthalmol Scand 2001;79:408-13. |
| 11. | Wittig EO. Ocular cysticercosis: An epidemiological study. Arq Neuropsiquiatr 2001;59:696-701. |
| 12. | Atul K, Kumar TH, Mallika G, Sandip M. Socio-demographic trends in ocular cysticercosis. Acta Ophthalmol Scand 1995;73:438-41. |
| 13. | Sekhar GC, Lemke BN. Orbital cysticercosis. Ophthalmology 1997;104:1599-604. |
| 14. | Sekhar GC, Honavar SG. Myocysticercosis: Experience with imaging and therapy. Ophthalmology 1999;106:2336-40. |
| 15. | Menon V, Tandon R, Khanna S, Sharma P, Khokhar S, Vashisht S, et al. Cysticercosis of the optic nerve. J Neuroophthalmol 2000;20:59-60. |
| 16. | Zee CS, Segall HD, Miller C, Tsai FY, Teal JS, Hieshima G, et al. Unusual neuroradiological features of intracranial cysticercosis. Radiology 1980;137:397-407. |
| 17. | Sihota R, Honavar SG. Oral albendazole in the management of extraocular cysticercosis. Br J Ophthalmol 1994;78:621-3. |
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