Orbital cysticercosis: varied presentations with management plan

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Introduction
Cysticercosis is the infestation by the larval form of the pork tapeworm Cysticercus cellulosae.It can be contracted by many modes such as ingestion of the infective cysticerci while consuming undercooked pork ingestion of eggs of T. solium in contaminated water, food or vegetables, or by regurgitation of eggs from the small intestine called as autoinfection

Study type and design:
A progressive observational study design followed for patients diagnosed with ocular cysticercosis.

Duration of study:
In the calendar year 2019 from Jan 2019 -Dec 2019, from the time of confirmation of diagnosis, patients were followed regularly for 6 months, starting from day 0, then weekly for 6 weeks then with every 2 weeks interval for next 6 weeks followed by 1-month interval for next 3 months.

Sampling method and sample size collection:
All patients for whom the diagnosis of ocular cysticercosis was confirmed were included in the study.

Ethical consideration and permission:
To carry out the study, necessary ethical clearance was taken from the institutional ethical committee.Medical management was given to all cases, which consisted of oral albendazole (15 mg/kg/day) in two divided doses along with prednisolone (1.5 mg/kg/day) in a single dose for four weeks.
Prednisolone was tapered off over the subsequent four weeks.Patients were followed regularly starting from day 0, then weekly for 6 weeks, then for every 2 weeks interval for the next 6 weeks followed by 1month interval for next 3 month All cases responded completely to the medical management.

Result
In our study out of the eight cases, five were males and three females.3 cases were in the age group 9 to 13 and 5 in the age group 14 to 35, thus the Median age was 19 years.The mean follows up period was 5 months.In this study, all the patients were taken up for medical management.B-scan ocular ultrasonography: It reveals a welldefined cystic lesion with clear contents and a hyperechoic area suggestive of a scolex [17].
Ocular ultrasonography is a useful tool not only for diagnosis but also for monitoring of the cyst during treatment.
CT scanning of the orbits is a reliable technique to help establish a diagnosis of ocular cysticercosis.
The characteristic feature is a hypodense mass with a central hyperdensity suggestive of the scolex.
Usually, a solitary cyst with wall enhancement is observed.Adjacent soft-tissue inflammation may be present.The scolex may not be visible if the cyst is dead or ruptured and has surrounding inflammation.
Concurrent neurocysticercosis may be present and should be excluded [6].
In our study, a CT scan of the orbit showed well defined hypodense cystic mass with peripheral wall enhancement.This was used as the confirmatory marker for cysticercosis.
Other tests that can help are serum Enzyme-Linked Immunosorbent Assay (ELISA) for anticysticercal antibodies and complete blood count.Positive ELISA test results help confirm the diagnosis in cases where scolex is not visible but negative results do not exclude cysticercosis.A complete blood count may reveal eosinophilia [18].It is usually given at 15 mg/kg per day with a maximum of 400 mg/bid (higher doses have been given) with repeated dosing as clinically warranted.What does the study add to the existing knowledge?

Treatment
more commonly occur where sanitary conditions are poor and where raw, undercooked pork and beef are routinely consumed [2].However, in endemic areas incidences are in the rise in vegetarians also.Appropriate sanitation and personal hygiene are important in the control of fecal contamination of water and food.Raw and improperly cooked food should be avoided, especially in endemic areas [3].Ocular cysticercosis is common in the Indian subcontinent [4].

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Albendazole and praziquantel are the larvicidal drugs used in the treatment of cysticercosis in humans.Once the diagnosis of orbital cysticercus is confirmed, it is of utmost importance to rule out intraocular and central nervous system involvement.Dying cysticercus releases its toxin and incites severe inflammatory reactions leading to vitreous and may lead to blindness.Hence it is mandatory to check for intraocular involvement of cysticercus cyst.Cure rates range from 60 to 85% in the usual dosing with most series showing albendazole yielding slightly higher cure rates [8].

Fig- 1 :
Fig-1: CT Scan showing enhancement of lateral rectus muscle with mild enhancement.Small ring-enhancing hypodense area measuring 9.5*8.4mmseen in the posterior aspect of the left lateral rectus muscle.Orbital cysts are best treated conservatively with a 4-week regimen of oral albendazole (15 mg/kg/d) in conjunction with oral steroids (1.5 mg/kg/d) in a tapering dose over a 1-month period.Albendazole is a well-tolerated broad-spectrum cytocidal drug and destroys approximately 85% of cysts with a single course.Albendazole has largely supplanted praziquantel because of slightly greater cure rates, decreased cost and increased availability Serial B-scan ocular ultrasonography or CT scanning of the orbit helps to follow the resolution of the cyst, which is recognized by the disappearance of the scolex.Cysticercosis can be prevented through practicing good hygiene measures, such as washing hands frequently, washing raw vegetables and fruits well

Sajid N. et al: Orbital cysticercosis: varied presentations 01
. Immunocompromised patients 02.Cysticercosis involving any other system than ocular 03.Age < 5 years Tropical Journal of Ophthalmology and Otolaryngology 2020;5(3) Discussion Demography: In today's scenario cysticercosis infestation is still common entity in the developing country.Poor hygiene, low sanitation, consumption of undercooked pig meat, and history of travel to endemic areas specifically increases the incidences of the spread of the disease.Endemic areas generally lie over the tropical belt and include sub-Saharan Africa, India, and East Asia [5].In India, 78% of the cases with ocular cysticercosis have been reported from states of Andhra Pradesh and Pondicherry [6,7].In our study, 7 patients were local to Uttar Pradesh, while 1 patient was a resident of Bihar working as a daily wage worker in our area.Usually its more common in younger age groups though any age can be affected.There is no gender predilection [8].In our study, the mean age was 19 years and 5 being males and 3 as females.Site of Lodgment: The larval form of cysticercosis can lodge anywhere in the eye.Depending on that cysticercosis of the eye can be intraocular or extraocular.Clinical picture: According to a study published in India, 12.8% of all cases of cysticercosis involve the eye or its adnexa [3].Ocular cysticercosis can cause considerable loss of sight depending on its location and time-lapse in starting treatment.CT Scan Brain and orbit was done in 4 patients and only brain CT in 1 patient.In all the orbital CT Scan well defined hypodense cystic lesion was seen Whereas brain CT was normal in all cases.

Table - 1: Clinical profile of orbital cysticercosis in 8 patients.
done Cystic lesion along optic nerve enclosed in O.N. sheath Brain CT-normal Medical Sajid N. et al: Orbital cysticercosis: varied presentations Tropical Journal of Ophthalmology and Otolaryngology 2020;5(3) Lid/Preseptal cysticercosis: in the eyelids it causes a mass or swelling that is subcutaneous, painless, and mobile and causing varying degrees of mechanical ptosis [5].suggestive of the scolex.In our study Absolute Eosinophil Count was done in all patients that were within the normal range.Stool Examination: It is done for examining adult T. solium worm or its eggs in suspected cases of myocysticercosis.
Medical management in orbital cysticercosis is extremely effective and achieves clinical resolution in most patients.06.Reddy PS, Satyendran OM.Ocular cysticercosis.