Skeletal Muscle Cysticercosis - ijhbrijhbr.com/pdf/122-126.pdf · Skeletal Muscle Cysticercosis Dr. Kandukuri Mahesh Kumar , Dr. V.Indira , Dr. Ravikanth Soni , Dr. Chintakindi ,

International J. of Healthcare and Biomedical Research, Volume: 2, Issue: 4, July 2014, Pages 122- 126

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www.ijhbr.com ISSN: 2319-7072

Case Report:

Skeletal Muscle Cysticercosis

Dr. Kandukuri Mahesh Kumar , Dr. V.Indira , Dr. Ravikanth Soni , Dr. Chintakindi ,

Dr. Divyagna. T , Dr. Konduru Omkareshwar

Department of Pathology, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, India

Corresponding author: Dr. Kandukuri Mahesh Kumar

Abstract:

Cysticercosis is a disease caused by cysticercus cellulosae, the larval form of tapeworm, Taenia solium. Cystic-

ercosis is endemic with high prevalence in most of the developing countries because of the co-existence of poor

sanitary conditions and domestic pig raising. Human cysticercosis occurs when eggs are ingested via faecal-oral

transmission from an infected host. The infected human becomes an accidental intermediate host, with development

of cysticercosis within various organs. The parasite has a strong predilection to involve central nervous system

(CNS). Solitary muscular and soft tissue involvement without central nervous system involvement is rare and often

presents a diagnostic challenge. Imaging and histopathological examination plays an important role in establishing

the diagnosis by demonstrating a scolex on MRI and/or ultrasound. We report a rare case of an anterior abdominal

wall cysticercosis diagnosed by ultrasonography and confirmed by histopathology.

Keywords: cysticercosis, skeletal muscle, taenia solium

INTRODUCTION

Cysticercosis is a systemic manifestation caused by

dissemination of the larval form of the pork

tapeworm, Taenia solium. A high prevalence has

been reported from the developing countries because

of the co-existence of poor sanitary conditions and

domestic pig raising without proper veterinary

control or surveillance systems (1) .It occurs mainly in

pork eating nations due to consumption undercooked

pork or measly pork. Humans are the definitive hosts

and carry intestinal adult tapeworm. Intermittent

faecal shedding of proglottids or free eggs occurs,

and the intermediate host (normally pigs) ingests the

excreted eggs in contaminated food or water.

Embryos penetrate the gastrointestinal mucosa of the

pig and are haematogenously disseminated to

peripheral tissues with formation of larval cysts.

When undercooked pork is consumed, an intestinal

tapeworm is formed again, completing the life cycle

of the worm. Human cysticercosis occurs when eggs

are ingested via faecal-oral transmission from a

tapeworm host. The human then becomes an

accidental intermediate host, with development of

cysticercosis within organs. Cysticercosis can affect

various organs the brain, spinal cord, muscles, orbit,

subcutaneous tissues and heart. The clinical

manifestation of the patient varies depending upon

the site of larval encystment, number of cyst and the

extent of associated inflammatory responses. Isolated

involvement of the soft tissues is very rare and can

potentially mimic other soft tissue lesions including

infective, inflammatory and neoplastic lesions.


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CASE REPORT

A 16 year old male patient came to the surgical

outpatient department with complaints of swelling

the right side of the abdomen since one month.

Initially no pain was experienced by the patient, but

since one week moderate to severe pain was

experienced. Patient also complained of fever, nausea

and vomiting since 3 days which led to apprehension

in the patient and made the patient report to the

hospital. On general physical examination patient

was conscious, coherent with temperature of 99.8

Fahrenheit. A swelling of size 2 x 2 cm is noted in

the right anterior abdominal wall (lumbar region) in

subcutaneous /muscular plane firm in consistency,

tender, skin over the swelling appeared normal.

Routine work up of patient was done – which was

non contributory. Specific investigations requested

were Ultrasound abdomen, Fine needle aspiration

cytology (FNAC).

Ultrasonography – possible diagnoses given were

Abscess/ infected cyst (? cysticercosis) within

muscular plane of right external oblique. (Fig. 1)

Fine Needle Aspiration Cytology (FNAC)

Cytosmears show few singly scattered cells (?

endothelial cells/ histiocytes with round to oval and

elongated nuclei with prominent nucleoli in a

hemorrhagic background mixed with few

lymphocytes.

Features were suggestive of benign soft tissue lesion

/? Inflammatory lesion.

Patient was posted for excision and the excised

specimen sent for histopathological examination.

Gross findings

We received gray brown to gray black soft tissue

mass measuring 1.5 x 1.2 cm. At the periphery of the

specimen a cystic area is noted measuring 0.4 cm

diameter. Tissue was all embedded, processed and

paraffin embedded tissue blocks were made. Tissue

sections were cut and stained with hematoxylin and

eosin.

FIGURE 1 – Showing Cystic lesion in

the right external oblique muscle.

FIGURE 1


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Microscopy

Sections show skeletal muscle bundles,

fibrocollagenous tissue and adipose tissue infiltrated

by dense population of eosinophils, lymphocytes and

plasma cells along with congested vessels. At one

focus there is acellular hyaline material suggestive of

cyst wall. (Fig 2, 3 & 4)

Features are suggestive of parasitic cyst –

Cysticercosis.

DISCUSSION

Cysticercosis is a parasitic infection caused by

Cysticercus cellulosae, the larval form of Taenia

solium where as the infestation of human intestine

with adult tapeworms is known as Taeniasis. Humans

are the only definitive host while both humans and

pigs can act as intermediate hosts. The mode of

transmission is feco-oral, the most common being the

consumption of raw or undercooked beef or pork,

water, or vegetables contaminated with Taenia eggs (

2). Children are commonly affected because of

increased chances of fomite infection (3). Encystment

of larvae can occur in almost any tissue. The most

frequently reported locations are skin, skeletal

muscle, heart, eye, and most importantly, the CNS (4).

In the CNS, it can localize in the parenchyma (grey

matter), ventricles (most commonly 4th ventricle),

cisterns, subarachnoid space and the spinal cord

(extra-medullary intra-dural). Involvement of the

central nervous system (CNS), known as

FIGURE 2 & 3- ( 10 X View & 40 X View)

Photomicrograph showing eosinophilic

acellular hyalinized cyst wall with surrounding

adipose tissue, fibro-collagenous tissue and

congested blood vessels.

FIGURE 4 – (40 X View) Photomicrograph

showing Eosinophils, lymphocytes and plasma

cells.

FIGURE 4

FIGURE 2 FIGURE 3

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neurocysticercosis (NCC), is the most clinically

important manifestation of the disease. It may present

with dramatic findings, and is an important

contributor to neurologic morbidity in developing

countries. It is also the major cause of acquired

epilepsy in the world (5). A special form, termed

cysticercosis racemosus is a conglomeration of cysts

in the subarachnoid space, is frequently seen in Latin

America (6).

Skeletal muscle encystment usually is asymptomatic

but may cause muscular pseudohypertrophy with a

heavy parasite burden. Cysts may cause spasms,

weakness, and pain and may create subcutaneous

nodules. Abdelwahab et al (6) reported a case of a 40-

year-old man with cysticercosis presenting as a

solitary tumor in the biceps brachii muscle. Magnetic

resonance imaging suggested a cyst and

histopathological diagnosis confirmed it as

cysticercosis. Solitary presentation of muscular

cysticercosis is extremely rare. Our case was also of

intramuscular cysticercosis involving the right

external oblique muscle. The intramuscular and

subcutaneous cysticercosis is seen most commonly

over the arms and chest and is characterized by

multiple, mobile, firm, subcutaneous nodules with

normal overlying skin. The nodules vary in size from

1 to 2 cm and are usually asymptomatic. It may be

painful in about 20% of the patients and there are

chances of abscess formation as well (7). The

differential diagnosis includes lipomas, epidermoid

cysts, neuroma, neurofibromas, pseudoganglia,

sarcoma, myxoma or tuberculous lymphadenitis.

Mani et al (8) presented a case of a solitary cysticercal

cyst that involved the anterior abdominal wall

musculature and was diagnosed with sonography.

Sonograms revealed a well-defined cystic lesion with

an eccentric hyperechoic area within it. An eccentric,

echogenic, pedunculated structure was seen within

the cystic area of the lesion without calcification.

Inflammation and hypervascularity in the

surrounding muscle was noted. Cysticercosis should

be kept in mind if lesions with similar morphologic

characteristics are encountered in the musculature or

subcutaneous tissues during sonographic

examination. Cardiac cysticercosis cases were also

reported in the literature which may lead to

conduction system abnormalities, abnormal rhythms

or rarely heart failure. Oral mucosa is a rare site for

cysticercosis. Mazhari et al(9) described eight cases of

cysticercosis involving the oral cavity, all presenting

with a solitary superficial mucosal nodule, of these

four were in the buccal mucosa, two in the lips, one

in the tongue and one in the gums. Involvement of

the breast is a rare presentation. Agnihotri et al (10)

reported the case of a 22 years young married woman

who presented with a painless mobile swelling in the

right breast. Histopathological examination revealed

the presence of typical cysticercus larva.

Cysticercosis of the breast is rare and it should be

considered as a differential diagnosis for a lump in

the breast.

Diagnostic tests include laboratory investigations

showing eosinophilia in the blood and CSF. But in

our case the peripheral blood smear showed

eosinophils within normal range. Biopsy of the

subcutaneous nodules, if any, will help in confirming

the diagnosis of the lesion. Only Serological tests are

nondiagnostic. These include, indirect

haemagglutination test and enzyme linked

immunosorbent assay (ELISA) which is about 80%

sensitive in CSF. Lately, the enzyme linked immuno

electro transfer blot (EITB) test has been introduced

and reported to be 100% sensitive in patients with

two or more viable lesions.

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Praziquantel and albendazole have been used

extensively in the treatment of cysticercosis and are

the accepted therapies. Cysticercosis is a preventable

faeco-oral transmitted infection. It is possible to

prevent infection by avoiding undercooked food and

pork, and water contamination with human faeces.

Care should be taken in places with poor hygiene or

meat inspection laws.

CONCLUSION

Cysticercosis of the abdominal wall is a rare entity

and a clinical diagnosis is challenging as it can mimic

other pathological entities which can be differentiated

by histopathology.

REFERENCES

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and porcine Taenia solium infection in perú.

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3. González AE, Lopez Urbina T, Tsang B et al. Transmission dynamics of Taenia solium and potential for

pig-to-pig transmission. Parasitol Int. 2006;55:131-5.

4. Jones TC. Cestodes (tapeworms). In: Mandell GL, Douglas RG Jr, Bennet JE, editors. Principles and

Practice of

5. Infectious Diseases. New York: Churchill Livinstone Inc. 1999; Pp:2183-5.

6. Garcia HH, Gilman R, Martinez M, Tsang VC, Pilcher JB, Herrera G et al. Cysticercosis as a major cause

of epilepsy in Peru. Lancet 1993; 341:197-200.

7. Kim JH, Suh SI, Kim JH, Kwon TH, Chung HS. Giant neurocysticercosis cyst in the cerebellar

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vegetarian: a rare and unusual pseudotumor. Skeletal Radiol 2003; 32:424-8.

9. Sorvillo FJ, Portigal L, Degiorgio C, Smith L, Waterman SH, Berlin GW, et al. Cysticercosis-Related

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10. Mani NB, Kalra N, Jain M, Sidhu R. Sonographic diagnosis of a solitary intramuscular cysticercal cyst. J

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11. Mazhari NJ; Kumar N; Jain S. Cysticercosis of the oral mucosa: aspiration cytologic diagnosis. J Oral

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Skeletal Muscle Cysticercosis - ijhbrijhbr.com/pdf/122-126.pdf · Skeletal Muscle Cysticercosis Dr. Kandukuri Mahesh Kumar , Dr. V.Indira , Dr. Ravikanth Soni , Dr. Chintakindi ,