- Email: [email protected]
Retroorbital optic nerve cysticercosis
American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Retroorbital optic nerve cysticercosis☆ Abstract A 23-year-old female patient presented with rapidly diminishing vision (Perception of light negative) and diplopia since the last 1 month along with orbital pain in the left eye since the last 15 days. A magnetic resonance imaging revealed a cystic lesion in the retroorbital part of the left optic nerve, beneath the sheath and in the medial rectus. A cyst in the retroorbital part of the optic nerve has rarely been reported. Patient was treated with intravenous corticosteroids resulting in dramatic visual recovery (visual acuity 6/12 and no diplopia). (See Figs. 1 and 2.) Cysticercosis is considered the most common parasitic disease of the central nervous system [1]. It also affects the eye, skeletal muscle, and subcutaneous tissue [2]. The extraocular muscle form is the most common type of orbital cysticercosis [3]. In the ocular form, the most favored sites are the vitreous and subretinal spaces [4]. Human cysticercosis is caused by encystment of the larval form of the swine tapeworm Taenia solium and more rarely Taenia saginata. Man acts as the intermediate host of T solium. Infection occurs on eating raw or inadequately cooked infected pork, consuming food or water contaminated with fecal matter containing ova, or due to autoinfection [5]. Cysticercosis is a major health problem in developing countries of Latin America, Asia, and Africa [1,3], especially in areas of poverty and poor hygiene [2]. Several isolated case reports on orbital and ocular cysticercosis are available in literature [6,7], but clinical studies [3,8] on the varied clinical presentations, choice of investigative modalities for diagnosis and follow-up, importance of imaging brain parenchyma, and effective treatment modalities are limited. Adequate knowledge of the above factors is important for early and prompt management of cysticercosis. If the parasite is left untreated, it eventually dies after 2 to 4 years, releasing toxins which induce intense inflammatory reaction and could lead to dreadful sequelae [9]. A 23-year-old female presented with progressively diminishing vision in the left eye along with double vision over 1 month and orbital pain since 15 days. General and systemic examination was normal except ophthalmological examination which showed visual acuity of 6/6 in the right eye and no perception of light in the left eye along with restricted adduction of left eye. The optic disc of both eyes was normal. There was absence of proptosis, vitreous reaction, and retinal abnormality. Routine hemogram, biochemistry, and stool examination were normal. Magnetic resonance imaging of the brain including both orbits revealed evidence of a diffuse thickening and hyperintense signals at retroorbital part of the left optic nerve. (See Figs. 1 and 2) Dilatation of optic nerve sheath was seen, which also showed enhancement suggestive of retro orbital optic neuritis. Thickening of left medial rectus muscle was seen showing ring enhancing lesion and small well defined mural nodule within it suggestive of cysticercus cyst. B-scan of left eye showed thickened left optic nerve with surrounding fluid and a well-defined cystic lesion with ☆ We declare that this manuscript has not been submitted elsewhere. There are no conflicts of interest.
eccentric echogenic dot in left medial rectus muscle. Patient was treated with intravenous corticosteroid for 5 days and followed by oral tapering of steroid. At the end of 1 month, visual acuity was 6/12, and there was no diplopia and relative afferent pupillary defect in left eye. Cysticercosis is an infestation by cysticercus cellulosae, the larval form of pork tapeworm. Common sites of encystment include subcutaneous tissue, 24.5%; brain, 13.6%; and eyes, 12.8% [10]. In the eye, the cyst may lodge in the vitreous, 51%; orbit, 18%; subretinally, 15%; and, least commonly, subconjunctivally, 3% [11]. Other rare sites are the anterior chamber [2] and the optic nerve. Presentation with optic nerve cysticercosis is rare. Until now, only 4 cases have been reported in literature [6,12,13,14]. As was seen in other reports, medical therapy failed to improve vision [14]. A complete surgical removal of cysts was done for all patients with intraocular cysticercosis with good surgical results. Early removal of the cyst is crucial in management of intraocular cysticercosis [9,15,16] because cyst, if allowed to undergo its spontaneous course, could lead to blindness [7]. Optic nerve cysticercosis may mimic an optic nerve tumor such as glioma [12] or an inflammatory granuloma [6], presenting with diminished vision and field loss. A surgical approach, however, is advocated in optic nerve cysticercosis considering the encouraging visual results as experienced in the few rare cases reported, but in our case, we have treated with steroid only leading to dramatic recovery. To conclude, a high index of suspicion should be kept in mind in endemic areas having greater risk due to poor hygiene and lack of health awareness. Visual morbidity can thus be significantly prevented by early diagnosis and treatment. Conservative treatment with steroid alone was very effective in our case obviating the need of surgical intervention. Therefore, steroid therapy is worth trying before heading for surgical intervention.
Rajendra Singh Jain DM *Jagdeesh Chandra Kookna MD Mahendra Singh Sisodia MD Indu Bhana MD Ibraheem Khan MD Department of Neurology, S.M.S. Medical College Jaipur, Rajasthan 302004, India *Corresponding author at: Department of Neurology, S.M.S. Medical College, Jaipur, Rajasthan 302004, India Tel.:+91 9414967709 Email Addresses: [email protected] (R.S. Jain), [email protected] (J.C. Kookna), [email protected] (M.S. Sisodia), [email protected] (I. Bhana), [email protected] (I. Khan)
http://dx.doi.org/10.1016/j.ajem.2016.05.057
0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Jain RS, et al, Retroorbital optic nerve cysticercosis, Am J Emerg Med (2016), http://dx.doi.org/10.1016/ j.ajem.2016.05.057
2
R.S. Jain et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
References [1] Coker-Vann MR, Subianto DB, Brown P, Diwan AR, Desowitz R, Garruto RM, et al. ELISA antibodies of cysticerci of Taenia solium in human populations in New Guinea, Oceania and South East Asia. Southeast Asian J Trop Med Public Health 1981;12:499–505. [2] Kapoor S, Kapoor MS. Ocular cysticercosis. J Pediatr Ophthalmol Strabismus 1978; 15:170–3. [3] Sekhar GC, Honavar SG. Myocysticercosis: experience with imaging and therapy. Ophthalmology 1999;106:2336–40. [4] Bartholowmew RS. Subretinal cysticercosis. Am J Ophthalmol 1975;79:670. [5] Swatz WG. Medical parasitology, 127. New York: McGraw-Hill; 1956[Received on November 20th, 2000. Accepted on February 5th, 2001]. [6] Madan VS, Dhamija RM, Gill HS, Boparai MS, Souza PD, Sanchete PC, et al. Optic nerve cysticercosis: a case report. J Neurol Neurosurg Psychiatry 1991;54:470–1. [7] George AE, Biswas J, Agarwal R, Kumarasamy N, Solomon S. Subretinal cysticercosis in a patient with AIDS: treatment with xenon arc photocoagulation. Retina 1999;19: 467–8. [8] Puri P, Grover AK. Medical management of orbital myocysticercosis: a pilot study. Eye 1998;12:795–9. [9] Gupta A, Gupta R, Pandav SS, Dogra MR, Joshi K. Successful surgical removal of encapsulated subretinal cysticercus. Retina 1998;18:563–6. [10] Malik SRK, Gupta AK, Choudhry S. Ocular cysticercosis. Am J Ophthalmol 1968;66: 1168–71. [11] Atul K, Kumar TH, Mallika G, Sandip M. Socio-demographic trends in ocular cysticercosis. Acta Ophthalmol Scand 1995;73:438–41. [12] Bousquet CF, Dufour TF, Derome PC. Retrobulbar optic nerve cysticercosis. J Neurosurg 1996;84:293–6. [13] Gurha N, Sood A, Dhar J, Gupta S. Optic nerve cysticercosis in the optic canal. Acta Ophthalmol Scand 1999;77:107–9. [14] 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. [15] Seo MS, Woo JM, Park YG. Intravitreal cysticercosis. Korean J Ophthalmol 1996;10: 55–9. [16] Natarajan S, Malpani A, Kumar Nirmalan P, Dutta B. Management of intraocular cysticercosis. 1999;237(10):812–4.
Fig. 1. MRI brain including both orbits T2W image revealed diffuse thickening and hyper intense signals at retro orbital part of the left optic nerve and Thickening of left medial rectus muscle was seen.
Fig. 2. T1W post contrast image showing ring enhancing lesion and small well defined mural nodule within left medial rectus suggestive of cysticercus cyst.
Please cite this article as: Jain RS, et al, Retroorbital optic nerve cysticercosis, Am J Emerg Med (2016), http://dx.doi.org/10.1016/ j.ajem.2016.05.057
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Retroorbital optic nerve cysticercosis☆ Abstract A 23-year-old female patient presented with rapidly diminishing vision (Perception of light negative) and diplopia since the last 1 month along with orbital pain in the left eye since the last 15 days. A magnetic resonance imaging revealed a cystic lesion in the retroorbital part of the left optic nerve, beneath the sheath and in the medial rectus. A cyst in the retroorbital part of the optic nerve has rarely been reported. Patient was treated with intravenous corticosteroids resulting in dramatic visual recovery (visual acuity 6/12 and no diplopia). (See Figs. 1 and 2.) Cysticercosis is considered the most common parasitic disease of the central nervous system [1]. It also affects the eye, skeletal muscle, and subcutaneous tissue [2]. The extraocular muscle form is the most common type of orbital cysticercosis [3]. In the ocular form, the most favored sites are the vitreous and subretinal spaces [4]. Human cysticercosis is caused by encystment of the larval form of the swine tapeworm Taenia solium and more rarely Taenia saginata. Man acts as the intermediate host of T solium. Infection occurs on eating raw or inadequately cooked infected pork, consuming food or water contaminated with fecal matter containing ova, or due to autoinfection [5]. Cysticercosis is a major health problem in developing countries of Latin America, Asia, and Africa [1,3], especially in areas of poverty and poor hygiene [2]. Several isolated case reports on orbital and ocular cysticercosis are available in literature [6,7], but clinical studies [3,8] on the varied clinical presentations, choice of investigative modalities for diagnosis and follow-up, importance of imaging brain parenchyma, and effective treatment modalities are limited. Adequate knowledge of the above factors is important for early and prompt management of cysticercosis. If the parasite is left untreated, it eventually dies after 2 to 4 years, releasing toxins which induce intense inflammatory reaction and could lead to dreadful sequelae [9]. A 23-year-old female presented with progressively diminishing vision in the left eye along with double vision over 1 month and orbital pain since 15 days. General and systemic examination was normal except ophthalmological examination which showed visual acuity of 6/6 in the right eye and no perception of light in the left eye along with restricted adduction of left eye. The optic disc of both eyes was normal. There was absence of proptosis, vitreous reaction, and retinal abnormality. Routine hemogram, biochemistry, and stool examination were normal. Magnetic resonance imaging of the brain including both orbits revealed evidence of a diffuse thickening and hyperintense signals at retroorbital part of the left optic nerve. (See Figs. 1 and 2) Dilatation of optic nerve sheath was seen, which also showed enhancement suggestive of retro orbital optic neuritis. Thickening of left medial rectus muscle was seen showing ring enhancing lesion and small well defined mural nodule within it suggestive of cysticercus cyst. B-scan of left eye showed thickened left optic nerve with surrounding fluid and a well-defined cystic lesion with ☆ We declare that this manuscript has not been submitted elsewhere. There are no conflicts of interest.
eccentric echogenic dot in left medial rectus muscle. Patient was treated with intravenous corticosteroid for 5 days and followed by oral tapering of steroid. At the end of 1 month, visual acuity was 6/12, and there was no diplopia and relative afferent pupillary defect in left eye. Cysticercosis is an infestation by cysticercus cellulosae, the larval form of pork tapeworm. Common sites of encystment include subcutaneous tissue, 24.5%; brain, 13.6%; and eyes, 12.8% [10]. In the eye, the cyst may lodge in the vitreous, 51%; orbit, 18%; subretinally, 15%; and, least commonly, subconjunctivally, 3% [11]. Other rare sites are the anterior chamber [2] and the optic nerve. Presentation with optic nerve cysticercosis is rare. Until now, only 4 cases have been reported in literature [6,12,13,14]. As was seen in other reports, medical therapy failed to improve vision [14]. A complete surgical removal of cysts was done for all patients with intraocular cysticercosis with good surgical results. Early removal of the cyst is crucial in management of intraocular cysticercosis [9,15,16] because cyst, if allowed to undergo its spontaneous course, could lead to blindness [7]. Optic nerve cysticercosis may mimic an optic nerve tumor such as glioma [12] or an inflammatory granuloma [6], presenting with diminished vision and field loss. A surgical approach, however, is advocated in optic nerve cysticercosis considering the encouraging visual results as experienced in the few rare cases reported, but in our case, we have treated with steroid only leading to dramatic recovery. To conclude, a high index of suspicion should be kept in mind in endemic areas having greater risk due to poor hygiene and lack of health awareness. Visual morbidity can thus be significantly prevented by early diagnosis and treatment. Conservative treatment with steroid alone was very effective in our case obviating the need of surgical intervention. Therefore, steroid therapy is worth trying before heading for surgical intervention.
Rajendra Singh Jain DM *Jagdeesh Chandra Kookna MD Mahendra Singh Sisodia MD Indu Bhana MD Ibraheem Khan MD Department of Neurology, S.M.S. Medical College Jaipur, Rajasthan 302004, India *Corresponding author at: Department of Neurology, S.M.S. Medical College, Jaipur, Rajasthan 302004, India Tel.:+91 9414967709 Email Addresses: [email protected] (R.S. Jain), [email protected] (J.C. Kookna), [email protected] (M.S. Sisodia), [email protected] (I. Bhana), [email protected] (I. Khan)
http://dx.doi.org/10.1016/j.ajem.2016.05.057
0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Jain RS, et al, Retroorbital optic nerve cysticercosis, Am J Emerg Med (2016), http://dx.doi.org/10.1016/ j.ajem.2016.05.057
2
R.S. Jain et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
References [1] Coker-Vann MR, Subianto DB, Brown P, Diwan AR, Desowitz R, Garruto RM, et al. ELISA antibodies of cysticerci of Taenia solium in human populations in New Guinea, Oceania and South East Asia. Southeast Asian J Trop Med Public Health 1981;12:499–505. [2] Kapoor S, Kapoor MS. Ocular cysticercosis. J Pediatr Ophthalmol Strabismus 1978; 15:170–3. [3] Sekhar GC, Honavar SG. Myocysticercosis: experience with imaging and therapy. Ophthalmology 1999;106:2336–40. [4] Bartholowmew RS. Subretinal cysticercosis. Am J Ophthalmol 1975;79:670. [5] Swatz WG. Medical parasitology, 127. New York: McGraw-Hill; 1956[Received on November 20th, 2000. Accepted on February 5th, 2001]. [6] Madan VS, Dhamija RM, Gill HS, Boparai MS, Souza PD, Sanchete PC, et al. Optic nerve cysticercosis: a case report. J Neurol Neurosurg Psychiatry 1991;54:470–1. [7] George AE, Biswas J, Agarwal R, Kumarasamy N, Solomon S. Subretinal cysticercosis in a patient with AIDS: treatment with xenon arc photocoagulation. Retina 1999;19: 467–8. [8] Puri P, Grover AK. Medical management of orbital myocysticercosis: a pilot study. Eye 1998;12:795–9. [9] Gupta A, Gupta R, Pandav SS, Dogra MR, Joshi K. Successful surgical removal of encapsulated subretinal cysticercus. Retina 1998;18:563–6. [10] Malik SRK, Gupta AK, Choudhry S. Ocular cysticercosis. Am J Ophthalmol 1968;66: 1168–71. [11] Atul K, Kumar TH, Mallika G, Sandip M. Socio-demographic trends in ocular cysticercosis. Acta Ophthalmol Scand 1995;73:438–41. [12] Bousquet CF, Dufour TF, Derome PC. Retrobulbar optic nerve cysticercosis. J Neurosurg 1996;84:293–6. [13] Gurha N, Sood A, Dhar J, Gupta S. Optic nerve cysticercosis in the optic canal. Acta Ophthalmol Scand 1999;77:107–9. [14] 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. [15] Seo MS, Woo JM, Park YG. Intravitreal cysticercosis. Korean J Ophthalmol 1996;10: 55–9. [16] Natarajan S, Malpani A, Kumar Nirmalan P, Dutta B. Management of intraocular cysticercosis. 1999;237(10):812–4.
Fig. 1. MRI brain including both orbits T2W image revealed diffuse thickening and hyper intense signals at retro orbital part of the left optic nerve and Thickening of left medial rectus muscle was seen.
Fig. 2. T1W post contrast image showing ring enhancing lesion and small well defined mural nodule within left medial rectus suggestive of cysticercus cyst.
Please cite this article as: Jain RS, et al, Retroorbital optic nerve cysticercosis, Am J Emerg Med (2016), http://dx.doi.org/10.1016/ j.ajem.2016.05.057