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CASE REPORT  
Year : 2013  |  Volume : 6  |  Issue : 3  |  Page : 303-305
Ocular cysticercosis causing isolated ptosis: A rare presentation


Department of Surgery (Neurosurgery unit), Jawahar Lal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

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Date of Web Publication7-Nov-2013
 

   Abstract 

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. Orbital cysticercosis presents with limitations of ocular motility in 75% of patients. We describe a case of orbital cysticercosis where the patient presented with isolated unilateral painless progressive ptosis and showed complete resolution after 1 month of treatment with Albendazole.

Keywords: Extraocular muscles, orbital cysticercosis, ptosis

How to cite this article:
Kamali NI, Huda MF, Srivastava VK. Ocular cysticercosis causing isolated ptosis: A rare presentation. Ann Trop Med Public Health 2013;6:303-5

How to cite this URL:
Kamali NI, Huda MF, Srivastava VK. Ocular cysticercosis causing isolated ptosis: A rare presentation. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Jun 3];6:303-5. Available from: http://www.atmph.org/text.asp?2013/6/3/303/120989

   Introduction Top


Ocular cysticercosis is very common in the Indian subcontinent both in vegetarian as well as nonvegetarian population. [1] Humans are the intermediate host of the causative agent Taenia solium and get affected by ingesting its eggs through contaminated food. Apart from central nervous system, cysticercosis may also invade the eyes, skeletal muscles, and subcutaneous tissues. Isolated unilateral ptosis due to orbital cysticercosis is exceedingly rare. We report an unusual presentation of cysticercosis in the form of isolated ptosis and its complete resolution after therapy with Albendazole.


   Case report Top


A 9-year-old girl presented to us with painless progressive ptosis of the left eye of 1 month duration. There was no history of loss of vision, double vision, painful eye movements, retro-orbital pain, tearing, redness, or protrusion of the eye balls. There was no history of headache, vomiting, or seizures.

On examination patient was a child of average built and nutrition. General physical and systemic examination was normal. Visual acuity was 6/6 in both the eyes. Both the pupils were normal in size and reaction. Alignment of eyes was within normal limits. Ocular ductions and versions appeared to be full in both the eyes. External examination showed the presence of severe ptosis in the left eye [Figure 1]a.
Figure 1: (a) Clinical photograph at presentation showing ptosis of left eye, (b) MRI at presentation: postcontrast coronal T1-weighted MRI shows enhancing, ring shaped lesion involving left superior rectus (arrow) suggestive of cysticercosis, (c) MRI at presentation: post contrast saggital T1-weighted MRI shows edema of left superior rectus (arrow)

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Anterior segment examination, posterior segment examination and field of vision were within normal limits in both the eyes. Intra-ocular pressure was 14 mmHg in the right eye and 12 mmHg in the left eye. Rest of the central nervous system examination was normal.

Hemogram, blood biochemistry, and chest radiograph were within normal limits.

Magnetic Resonance Imaging (MRI) of the orbit revealed a well-defined cystic lesion with an eccentric nodule in the muscle belly of the left superior rectus with surrounding edema and ring like enhancement suggestive of cysticercosis involving left superior rectus muscle [Figure 1]b and c. Hence a diagnosis of left sided ptosis as a manifestation of orbital cysticercosis was made. Enzyme Linked Immuno Sorbent Assay (ELISA) for Taenia solium was positive. The patient was managed conservatively with Albendazole at dose of 15 mg/kg/day for 1 month. The ptosis resolved completely over a period of 1 month [Figure 2]a. Repeat MRI showed resolution of the previously seen cysticercal lesion in the left superior rectus complex [Figure 2]b and c.
Figure 2: Posttreatment clinical photograph showing resolution of ptosis of left eye in forward gaze, (b) MRI after treatment: noncontrast coronal T1-weighted image shows complete resolution of lesion in left superior rectus (arrow indicates absence of lesion), (c) MRI after treatment: post contrast saggital T1-weighted MRI shows resolution of lesion in left superior rectus (arrow shows absence of lesion)

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   Discussion Top


Cysticercosis is caused by seeding of larval form of Taenia solium in various body tissues following hematogenous spread. It is the most common parasitic infection of the central nervous system. It may also invade the eyes, skeletal muscles, and subcutaneous tissues. Cysticersosis is a serious health problem in Latin America, Asia, and Africa, especially in the areas of poor sanitation. [1]

Cysticerci can lodge themselves in any part of the ocular and extra-ocular tissue of the orbit. In the western literature, ocular or adnexal involvement occurs in 13-46% of the infected patients and posterior segment of the eye is the most frequent site affected. [2] As per the Indian literature, ocular involvement occurs in 1.8-4.5% cases only, the ocular adnexa being the preferred site. [3]

In an Indian study, the most common presenting feature of extra ocular muscle cysticercosis was limitation of ocular motility in 75% of the patients, while ptosis was present in only 28.1% of the patients. [4] Cysticercosis causing ptosis has been reported in literature. There are reports of midbrain neurocysticercosis causing sudden onset ptosis. [5],[6] There are also reports of ptosis developing following involvement of the extraocular muscles. [7],[8] In these studies, ptosis was associated with other symptoms, such as headache, proptosis, conjunctival congestion, and limitation of the eye movements. Our case is unique, as the patient presented with isolated painless progressive ptosis without any other associated clinical sign. In our study, superior rectus muscle was involved, which is very uncommon. In a case series of nine cases of extra-ocular muscle cysticercosis, Pushkar et al. showed that cysticercosis most commonly involved the medial rectus, followed by lateral rectus and finally superior oblique. [9] Use of steroids with albendazole has been advocated for the treatment of such patients. However, use of albenazole as monotherapy was advocated by Silhota et al. [10] We elected to treat our patient with albendazole alone at a dose of 15 mg/kg body weight daily for 1 month and the patient responded fully to it. The ptosis resolved completely within 1 month without any complication.


   Conclusion Top


It is thus concluded that orbital cysticercosis can present unusually in the form of isolated unilateral painless progressive ptosis. Albendazole monotherapy is equally effective in orbital cysticercosis as compared with treating it combined with steroids.

 
   References Top

1.Coker-Vann MR, Subianto DB, Brown P,Diwan AR, Desowitz R, Garruto RM. et al. ELISA antibodies to cysticerci of Taenia solium in human populations in New Guinea, Oceania and Southeast Asia. Southeast Asian J Trop Med Public Health 1981;12:499-505.  Back to cited text no. 1
    
2.Kaliaperumal S, Rao VA, Parija SC. Cysticercosis of the eye in South India - a case series. Indian J Med Microbiol 2005;23:227-30.  Back to cited text no. 2
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3.Wadia NH. Neuro-Cysticercosis. Neurol Pract Indian Perspect 2005;215-51.   Back to cited text no. 3
    
4.Murthy R, Samant M. Extraocular muscle cysticercosis: clinical features and management outcome. Strabismus 2008;16:97-106.  Back to cited text no. 4
    
5.Singhi P, Mahajan V, Khandelwal NK. Sudden-onset ptosis caused by midbrain neurocysticercosis in 2 children. J Child Neurol 2008;23:334-7.  Back to cited text no. 5
    
6.Sundarka M. Bilateral ptosis due to neurocysticercosis in the midbrain. Nepal J Neurosci 2005;2:137.  Back to cited text no. 6
    
7.Khwaja GA, Singh AC, Chaudhry N, Gupta M, Chowdhury D. Recurrent headache and unilateral ptosis as a manifestation of extra-ocular cysticercosis. JIACM 2008;9:218-20.  Back to cited text no. 7
    
8.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.  Back to cited text no. 8
    
9.Pushker N, Bajaj MS, Chandra M, Neena. Ocular and orbital cysticercosis. Acta Ophthalmol Scand 2001;79:408-13.  Back to cited text no. 9
    
10.Sihota R, Honavar SG. Oral albendazole in the management of extraocular cysticercosis. Br J Ophthalmol 1994;78:621-3.  Back to cited text no. 10
    

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Correspondence Address:
Nasib Iqbal Kamali
Senior resident (Neurosurgery), Jawaharlal Nehru medical college, Aligarh Muslim University, Aligarh, Utter Pradesh - 202 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.120989

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