|Year : 2015 | Volume
| Issue : 2 | Page : 160-162
An interesting case of presumed intraocular cysticercosis masquarading as posterior uveitis
Avinash Mishra Lt. Col 1, Somesh Aggarwal2, Vinod Kumar Baranwal3, Neeraj Bargava4
1 Department of Ophthalmology, Military Hospital, Ahemdabad, India
2 Vitero-Retinal Surgeon, M & J Western Regional Institute of Ophthalmology, Ahemdabad, India
3 Command Hospital (NC), Udhampur, India
4 Command Hospital (SC), Pune, India
|Date of Web Publication||13-Jul-2015|
Classified Specialist, Department of Ophthalmology, Military Hospital, Ahemdabad, Gujarat
Source of Support: None, Conflict of Interest: None
Uveitis occurs in relation with a wide variety of infectious, non infectious and immune-mediated disorders with. Besides these there are also some diseases which masquerade as uveitis, thus further complicating the issue and posing a diagnostic challenge. In such cases timely rapid and accurate diagnosis of the underlying cause as well as its correct management are of paramount importance in achieving a successful outcome. Here we report an interesting case of ocular cystecercosis, in a young lady who presented late with features of posterior uveitis and a severe loss of vision. She was managed aggressively and could be finally discharged with a significant visual improvement.
Keywords: Masquerade, ocular cystecercosis, posterior uveitis
|How to cite this article:|
Mishra A, Aggarwal S, Baranwal VK, Bargava N. An interesting case of presumed intraocular cysticercosis masquarading as posterior uveitis. Muller J Med Sci Res 2015;6:160-2
|How to cite this URL:|
Mishra A, Aggarwal S, Baranwal VK, Bargava N. An interesting case of presumed intraocular cysticercosis masquarading as posterior uveitis. Muller J Med Sci Res [serial online] 2015 [cited 2022 Jan 25];6:160-2. Available from: https://www.mjmsr.net/text.asp?2015/6/2/160/160697
| Introduction|| |
Uveitis occurs in relation to a wide variety of infectious, non-infectious and immune-mediated disorders some being either life-threatening systemic diseases and/or vision-threatening ocular complications. In addition, some diseases may masquerade as uveitis, thus posing a further diagnostic challenge. In such cases a timely diagnosis of the underlying cause as well as its correct management are of paramount importance in achieving a successful outcome. Here we report a case of ocular cystecercosis, which presented late with features of posterior uveitis and a severe visual loss. She was managed aggressively and finally discharged with a significant visual improvement.
| Case Report|| |
A 29 year old lady presented with severe diminution of vision in her left eye. She was apparently asymptomatic till about 9 months back, when she noticed floaters along with a decreased vision in her left eye. She consulted a local ophthalmologist and was prescribed corrective glasses. Initially the patient claimed a mild improvement in her vision, however the floaters persisted. About 6 months later the patient reported again with a further decrease in vision. Dilated fundoscopy was now carried out and subsequently she was referred to this centre with a diagnosis of opacified vitreous due to a suspected old vitreous haemorrhage. On examination the left eye vision was 1/60, while the right eye was a normal 6/6. The intra ocular pressure was a normal 15 mm Hg in both eyes, as measured by a non contact tonometer (NCT). Anterior segment examination of both eyes was normal. Slit lamp biomicroscopy revealed vitritis in the left eye. On dilated fundoscopy, cotton wool vitreous opacities were noticed in the left eye; however details could not be clearly seen. The right eye examination was essentially normal. Usg B scan revealed multiple translucent opacities in the mid and posterior vitreous as well as retinal detachment [Figure 1]. A probable diagnosis of posterior uveitis associated with tractional retinal detachment (TRD) was made. Since the patient was not a known case of any major disease, she was thoroughly investigated for uveitis [Table 1], however the tests were all normal. Simultaneously treatment was started with systemic high dose steroids i.e. tablet prednisolone 60 mg once daily along with broad spectrum antibiotics. Topically, antibiotics (eye drop moxifloxacin 2 hourly), steroids (eye drop prednisolone 1 hourly) as well as mydriatics (eye drop homatropine 2%, 6 hourly) were also started. These were gradually tapered off over the next 5 weeks. Under treatment, the patient improved, with a significant clearing of the vitreous opacities and vision improving to 6/60 within 1 week. A detailed fundus examination was now possible and it revealed a tractional band in the upper nasal quadrant periphery [Figure 2] along with a cystic lesion in the inferior quadrant [Figure 3]. Usg B scan now repeated showed an oval vesicle-like echogenic mass in the vitreous [Figure 4]. A probable diagnosis of cystecercosis was made and the patient was further investigated with a computed tomography (CT) scan of the brain and orbits; however it was normal, with no evidence of neurocystecercosis. By the end of 4 weeks the patient's vision had improved to 6/9 and she was started on anti-helminthics (tablet albendazole 400 mg) daily for the next 7 days. This was done under the cover of steroids and keeping a careful watch for any anaphylaxis. Fundus examination after the course of antihelminthics revealed a resolution of the uveitis.
|Figure 1: Usg B scan showing multiple translucent opacities in the mid and posterior vitreous as well as retinal detachment|
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|Figure 2: Fundus photograph showing a tractional band in the upper nasal quadrant periphery|
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|Figure 3: Fundus photograph showing a cystic lesion in the inferior quadrant|
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|Figure 4: Usg B scan again repeated showed an oval vesicle-like echogenic mass in the vitreous chamber|
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|Table 1: Investigations carried out to detect the cause of posterior uveitis in the patient|
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The patient was finally discharged with a vision of 6/6 (p) in the left eye, however she is on a regular OPD follow-up.
| Discussion|| |
Cysticercosis is due to cysticercus cellulosae, the larval form of the helminth Taenia solium, commonly known as the pork tapeworm.  Human cysticercosis is acquired by ingesting the eggs shed in faeces i.e. fecal contamination of vegetables such as cabbage, cauliflower etc. or by eating inadequately cooked pork.  Humans thus become the intermediate hosts in the life cycle of Taenia solium. 
It is particularly common in developing countries, among people of lower socioeconomic status with a poor personal hygiene.  The commonest sites of involvement are the soft tissues, the eyes and the central nervous system. 
The pathophysiological sequence in intraocular cysticercosis is as follows: The taenia egg develops into a cysticercus in the small intestine. It then penetrates through the duodenal wall and enters the bloodstream. Subsequently through the central retinal artery it reaches the vitreous. It may even pass through the short posterior ciliary artery into the choroid, to finally reach the vitreous.  Here it releases toxins which result in local granulomatous inflammation along with fibrous tissue proliferation. Initially retinal edema, exudation, and vitreous hemorrhage occur. Subsequently a large number of inflammatory cells infiltrate into the vitreous, retina, and choroid, leading to uveitis, retinal and vitreous proliferation, retinal vascular occlusion, and sometimes even an exudative retinal detachment.  Once the vesicle wall ruptures, the parasite dies, releasing more toxins into the vitreous and hence a severe histoclasia along with visual impairment. 
Though in our case the diagnosis of intraocular cysticercosis was only made after a detailed fundoscopy was possible and later on confirmed by a Usg B scan , however usually radiological investigations i.e. B-ultrasound, CT and magnetic resonance imaging (MRI) help in initially diagnosing ocular cysticercosis , both during the living as well as its dead stage. 
A combination therapy with albendazole and steroids has been of proven benefit in the management of extraocular cysticercosis and the patients too usually respond significantly , Whereas patients with intraocular cysticercosis usually requires a more aggressive management, often in the form of intra ocular surgery and in addition is also associated with a poor visual recovery. ,
| Conclusion|| |
The hallmark of this case which makes it so very interesting is that this patient had presented with only features of severe posterior uveitis, and since initially no cause was detected, she was managed with systemic steroids. Once the vitreous cleared, the cyst was observed, and oral albendazole added to the treatment. Intraocular cysticercosis usually requires surgical intervention and is also often associated with a poor visual prognosis. However no surgery was contemplated in our case because of complete resolution of uveitis along with a significant improvement in her vision, with conservative treatment only.
Awareness of the various atypical presentations of cystecercosis and understanding their pathogenesis will make us better clinicians and go a long way in providing better patient care.
| References|| |
Bernardin P, Auzemery A, Rabenantoandro C. Ocular cysticercosis (O.C.) in Madagascar (apropos of 6 cases). Rev Int Trach Pathol Ocul Trop Subtrop Sante Publique 1994;71:103-13.
Auzemery A, Andriantsimahavandy A, Esterre P, Bouat C, Boitte JP, Huguet P. Ocular cysticercosis. Med Trop (Mars) 1995;55:429-33.
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.
Wu D, Guo YJ, Lin Y, Sun SH. Protective immunity induced by DNA vaccine of Cysticercus cellulosae antigen. Acad J Sect Mil Med Univ 2000;21:508-10.
Madigubba S, Vishwanath K, Reddy G, Vemuganti GK. Changing trends in ocular cysticercosis over two decades: An analysis of 118 surgically excised cysts. Indian J Med Microbiol 2007;25:214-9.
Kaliaperumal S, Rao VA, Parija SC. Cysticercosis of the eye in South India - a case series. Indian J Med Microbiol 2005;23:227-30.
Shi D, Li S, Guo Y, Guo X. A diagnostic analysis of imaging in ocular cysticercosis. Zhonghua Yan Ke Za Zhi 2000;36:56-8, 8.
Murthy R, Samant M. Extraocular muscle cysticercosis: Clinical features and management outcome. Strabismus 2008;16:97-106.
Labh RK, Sharma AK. Ptosis: A rare presentation of ocular cysticercosis. Nepal J Ophthalmol 2013;5:133-5.
Li JJ, Zhang LW, Li H, Hu ZL. Clinical and pathological characteristics of intraocular cysticercosis. Korean J Parasitol 2013;51:223-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]