Ocular cysticercosis causing isolated ptosis: A rare presentation

How to cite this article:
Jain RS, Nagpal K, Prakash S, Handa R. Ocular cysticercosis causing isolated ptosis: A rare presentation. Ann Trop Med Public Health 2014;7:152-3

 

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Jain RS, Nagpal K, Prakash S, Handa R. Ocular cysticercosis causing isolated ptosis: A rare presentation. Ann Trop Med Public Health [serial online] 2014 [cited 2017 Nov 14];7:152-3. Available from: http://www.atmph.org/text.asp?2014/7/2/152/146457

Dear Sir,

We read with keen interest the article entitled “Ocular cysticercosis causing isolated ptosis: A rare presentation” by Kamali et al., (2013). [1] We certainly agree that neurocysticercosis is a common parasitic infection in Indian context, but ptosis as a presenting featurealongwith involvement of extraocular muscles is exceedingly rare.

We also came across a similar case of a 14-year-old nonvegetarian girlwho presented with acute onset, moderate to severe, throbbing headaches for 1 month. Over next 15 days, she developed swelling over entire face, had acute onset bilateral asymmetrical ptosis (left > right) associated with other features of right third nerve palsy, but with pupillary sparing [Figure 1]a and b. In addition, there was involvement of fourth cranial nerve on left side. Her vision and bilateralfundi were normal. Curiously, she had right-sided infranuclear facial weakness as well. However, rest of the neurological examination was normal.

Her detailed hematology and biochemical parameters revealed only a high erythrocyte sedimentation rate (70 mm). Subsequently, she underwent contrast magnetic resonance imaging (MRI; 3Tesla) of brain and orbits; which revealed focal, well-defined, hyperintense cystic lesions in bilateral medial rectus [Figure 1]c, bilateral superior rectus and superior oblique muscles [Figure 1]e with post contrastring enhancement, and edema with diffuse swelling in the bulk of muscles which were suggestive of neurocysticercosis. Interestingly, there was hyperintense signal seen in MRI-short tau inversion recovery (STIR) imagesin preparotid course of right facial nerve [Figure 1]d. We corroborated facial nerve involvement to possible underlying edema. She underwent ocular sonography as well, which ruled out the presence of intraocular cyst. Eventually, her serum IgG cysticercosis antibody (Taenia solium) came out to bepositive.

Figure 1: (a) Pretreatment images showing left > right ptosis with restricted ocular movements and right infranuclear facial palsy. (b) Post treatment images showing improvement in ptosis. (c) Cystic granulomas ring enhancement in bilateral medial rectus muscles on MRI brain axial post-contrast images, (d) MRI-STIR images showing hyperintense signals in right facial nerve in its preparotid course. (e) Sagittal MRI brain post-contrast images showing ring enhancing granulomas in superior oblique muscle. MRI = Magnetic resonance imaging, STIR = Short tau inversion recovery

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She showed remarkable recovery in ptosis within travenous dexamethasone given for 14 days [Figure 1]b and better excursion of extraocular movements. She even had resolution of cysts in follow-up neuroimaging. The associationof orbital cysticercosis with involvement of unilateral infranuclear facial nerve, as found in our case, has not been reported in the literature to the best of our knowledge.

The authors did mention that their patient underwent enzyme-linked immunosorbent assay (ELISA) for T. solium which was positive; but whether it was in CSF or serum sample, was not clarified. Also, authors should have considered a B-scan ultrasound of the orbit to rule out any intraocular cyst. Finally, authors advocated the administration of albendazole monotherapy in their patient who showed a satisfactory response to therapy; however, clinicians should be extremely cautiousin administering cysticidal therapy in orbital cysticercosis, as it may increase the edema and thereby resulting in severe visual compromise.

Cysticercosis of the extraocular muscles present with recurrent inflammation, restricted mobility, proptosis, and ptosis. [2],[3] In some sporadic reports, ptosis and restricted ocular motility was also seen in cysticerci infestation in midbrain. [4],[5] With its variable presentation clinical diagnosis of extraocular cysticerci is always speculative; hence, for subacute ptosis, a detailed neuroimaging involving orbits and brain parenchyma is always warranted in Indian context.

References

 

1.
Kamali NI, Huda MF, Srivastava VK. Ocular cysticercosis causing isolated ptosis: A rare presentation. Ann Trop Med Public Health 2013;6:303-5.
2.
Sekhar GC, Lemke BN. Orbital cysticercosis. Ophthalmology 1997;104:1599-604.
3.
Rath S, Honavar SG, Naik M, Anand R, Agarwal B, Krishnaiah S, et al. Orbital cysticercosis: Clinical manifestations, diagnosis, management, and outcome. Ophthalmology 2010;117:600-5.
4.
Naphade PU, Singh MK, Garg RK, Rai D. Bilateral ptosis: An atypical presentation of neurocysticercosis. BMJ Case Rep 2012;2012.
5.
Bhattacharya AK, Mitra K. Bilateral internuclear ophthalmoplegia. An atypical presentation of neurocysticercosis. J Indian Acad Clin Med 2006;7:64-7.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.146457

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