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Oral cysticercosis: A rare case presentation with ultrasound and MRI findings
Article · January 2015
DOI: 10.4103/0972-1363.170178
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Revath Vyas Devulapalli
Lakshmi Kavitha Nadendla
Legacy clinics, KIGALI, Rwanda
kamineni institute of dental sciences
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Case Report
Oral cysticercosis: A rare case presentation
with ultrasound and MRI findings
Revath Vyas Devulapalli, Balaji Babu Bangi, Lakshmi Kavitha Nadendla, Archana Pokala
Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Narketpally, Telangana, India
ABSTRACT
Taenia solium, the larvae of pork tapeworm, can cause the parasitic infection known as cysticercosis. It is commonly
seen in developing countries. The World Health Organization estimates that over 50,000 deaths per year are caused by
neurocysticercosis worldwide. It can occur anywhere in the body. Cysticerci in the muscles generally do not cause symptoms;
they present as nodules and can be felt as lumps under the skin or they can present as muscular pseudohypertrophy. The
condition rarely involves musculature of the orofacial region and presents a difficulty in clinical diagnosis. Here, we present
a case report of a healthy middle-aged female patient who had a painless swelling below the lower lip. The ultrasound
examination revealed an intramuscular cysticercosal cyst. The diagnosis was confirmed using magnetic resonance imaging
and by histopathology. The case was managed by conservative enucleation of the cyst.
Key words: Cysticercosis, diagnosis, magnetic resonance imaging, Taenia solium, ultrasonography
T
Introduction
aenia solium or pork tapeworm, a cyclophyllid
cestode, has three distinct morphological
verities.[1] Of these, cellulose cysticercus type
has a fluid-filled bladder with an invaginated scolex.
Human beings are infected by eating uncooked or
partially cooked pork, which is an intermediate host
for cysticercus cellulose. Sometimes humans act as
intermediate hosts, where eggs laid by larva develop
in the alimentary tract. They may enter the alimentary
tract as a result of retroperistalsis or by having food
or by using hands contaminated with those eggs.[2]
Encystment of larvae can occur in the central nervous
system, subcutaneous tissue, striated muscle, and rarely
in other tissues. High muscular activity and metabolic
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DOI:
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rate of oral tissues in humans might act against the
lodgment and development of cysticercosis in this
location.[3] Here, we present one such rare presentation
of oral cysticercosis in the mentalis muscle.
Case Report
A healthy, 30-year-old female patient visited the
outpatient department with the complaint of a painless
firm, non-tender swelling measuring approximately
2 cm × 2 cm on the left side, below the lower lip [Figure 1].
The swelling was present since 5 months. Swelling was
sudden in onset and gradually increased in size for
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How to cite this article: Devulapalli RV, Bangi BB, Nadendla LK,
Pokala A. Oral cysticercosis: A rare case presentation with
ultrasound and MRI findings. J Indian Acad Oral Med Radiol
2015;27:322-6.
Address for correspondence: Dr. Revath Vyas Devulapalli, Department of Oral Medicine and Radiology, Kamineni Institute of
Dental Sciences, Narketpally, Nalgonda District, Telangana, India. E-mail: revath.vyas@gmail.com
Received: 04-12-2015 Accepted: 12-10-2015 Published: 21-11-2015
322
© 2015 Journal of Indian Academy of Oral Medicine and Radiology | Published by Wolters Kluwer - Medknow
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Devulapalli RV et al.: Oral cysticercosis
2 months. Later, it remained constant in size. There
were no palpable cervical lymph nodes. The patient had
no headache, seizure, or any focal neurological deficit.
There was no family history of similar complaints in
other family members. Patient consumes mixed diet,
but never consumed pork. Intraorally, the swelling was
causing obliteration in the vestibular region of 32, 33, and
34 [Figure 2]. The lesion appeared to be peripheral in
origin, well encapsulated, present subcutaneously, freely
mobile, and not attached to the underlying periosteum.
Based on these clinical features, pre-operative provisional
diagnosis of fibroma was made. Under differential
diagnosis, lesions such as lipoma, pleomorphic adenoma,
and peripheral adenomatoid odontogenic tumor were
considered. Fibroma was considered because it is the
most common benign connective tissue tumor and can
occur anywhere in the oral cavity as a firm, painless
swelling in the 3rd to 5th decade of life. But generally it
occurs as a reactive lesion rather than a benign tumor,
and it more commonly occurs on the buccal mucosa and
tongue as a pedunculated mass. Lipoma was considered
because it can occur more commonly in females as a
painless swelling with a smooth surface. Yellowish
color and slip sign that are characteristic of superficially
present lipoma were not seen in this case. Pleomorphic
adenoma in the lower vestibule is unusual, but may
develop from the lower lip and extend into the vestibule.
Peripheral odontogenic lesions are very rare, but can
occur close to soft tissues adjacent to the tooth apparatus.
Conventional radiographs like periapical radiographs,
mandibular cross-sectional occlusal radiograph,
and orthopantomograph showed no bony changes,
confirming the lesion to be peripheral. On ultrasound
examination (USG), there was a well-defined hypoechoic
area measuring 1.75 cm × 1.8 cm and containing a small
echogenic mass at one end close to the bone [Figure 3].
The USG picture suggested a benign, thick-walled
cystic lesion surrounding a nidus. This nidus most
probably appeared to be the scolex of the larva. Based
on the USG, a probable diagnosis of cysticercosis in
the left mentalis muscle was made. To check for any
bony involvement, computed tomography (CT) of the
mandible was performed. To exclude the possibility of
any involvement of brain and other orofacial regions,
magnetic resonance imaging (MRI) was performed. The
CT showed [Figure 4] hypodense lesion within the soft
tissues causing scalloping of the cortical bone, which
may be a pressure indentation caused by the lesion.
Figure 2: Intraoral photograph showing solitary diffuse swelling in
the lower lip causing vestibular obliteration
Figure 1: Extraoral photograph showing solitary diffuse swelling in
the chin region on the left side
Figure 3: Ultrasound image showing a well-defined hypoechoic (H)
area with an echogenic nidus (E) at one end suggestive of larval head
or scolex
Figure 4: Axial and sagittal sections of T1 MRI picture showing
hypointense lesion in the mentalis region with an eccentrically placed
hyperintense nidus seen in axial section suggestive of scolex of the larva
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Devulapalli RV et al.: Oral cysticercosis
The MRI showed a lesion within the mentalis muscle,
which was hypointense in T1 [Figure 5] and hyperintense
in T2 [Figure 6], suggestive of fluid within the lesion.
Scolex of the larva was better seen in T1 images as
a hyperintense nidus close to the alveolar bone. No
evidence of disseminated or intracranial cysticercosis
was found in the MRI. The findings in MRI supported
cysticercosis as a radiological diagnosis.
A mucosal incision [Figure 7] was given to expose the
mass which was translucent. Mentalis muscle fibers were
resected and the cystic mass was separated from all the
muscle attachments with utmost care, and complete
enucleation of the cyst [Figure 8] was done. The specimen
was sent for histopathology. Gross specimen [Figure 9]
was approximately 2 cm × 2 cm in diameter. When the
specimen was cut open, it yielded plain water-like fluid,
which was fixed on a slide for cytological examination.
The inner surface of the specimen was white in color
and showed the scolex of the larva as an evagination
from the cystic wall [Figure 10]. Cytological examination
of the cystic fluid showed no associated inflammatory
component. Microscopic examination of the cystic lining
showed well-defined host capsule surrounding the cyst
and artifactual space created by shrinkage of the larvae
[Figure 11]. Host capsule showed duct-like invaginations
and inflammatory cell infiltrate [Figure 12]. With these
characteristic histological findings, a definitive diagnosis
of cysticercosis was made. As a precaution and to
treat any disseminated infection, anti-helminthic drug
albendazole 400 mg twice daily was prescribed for 28
days and a periodic follow-up was advised.[4] Patient is
under follow-up, with no recurrence and with no other
complaint.
Discussion
Cysticercus cellulosae is a rare condition in human
beings. Oral cysticercosis is still rarer and up to
2010, only 135 cases were reported in the English
literature. [5] Oral cysticercosis usually manifests as
painless, nodular masses. Most of the cases reported
in the literature presented with such painless, nodular
masses. [4] Cysticercosis is rarely included in the
pre-operative differential diagnosis due to the relative
rarity of the condition, inadequate knowledge of
parasitic infections and their oral manifestations,
and most importantly, due to negligence at the time
of taking the medical history. Modern radiological
modalities such as USG, CT, and MRI are very effective
in detecting cysticerci pre-operatively. [6] Except for a
Figure 5: Axial and coronal sections of T2 MRI picture showing a
well-defined hyperintense lesion within the mentalis muscle
Figure 6: Axial section showing scalloping and 3D CT section showing
depression on the labial surface of mandible caused by the overlying
well-defined hypodense lesion
Figure 7: Photograph showing surgical incision exposing the underlying
translucent lesion
324
Figure 8: Photograph showing enucleation of the cyst
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Devulapalli RV et al.: Oral cysticercosis
Figure 9: Gross specimen of size approximately 20 mm × 20 mm × 15 mm
Figure 11: Microscopic examination of the cystic lining showing
well-defined host capsule surrounding the cyst and artifactual space
created by shrinkage of the larvae
few cases in which fine needle aspiration cytology
was performed pre-operatively, [7] almost all the
reported lesions had been diagnosed as cysticercosis
only after histopathologic examination. Our case was
one such case diagnosed pre-operatively based on
USG and MRI. In this case report, we emphasize the
importance of radiological examination for a proper
pre-operative diagnosis. The diagnostic feature of
a cysticercus granuloma is the presence of an oval
or rounded well-defined hypoechoic cystic lesion
with smooth walls and an eccentric hyperechoic
nidus representing the scolex within. The cyst,
particularly the scolex, may be better visualized
by USG than MRI, in muscular lesions. [8] Diagnosis
can be done precisely with various serological
laboratory methods. [9,10] Laboratory findings in
patients with cysticercosis reveal eosinophilia, raised
immunoglobulin E (IgE), and most importantly, a
positive enzyme-linked immunosorbent assay (ELISA)
test against cysticercus cellulosae. In our case, no
specific laboratory investigations for cysticercosis were
Figure 10: Cut section of the gross specimen showing milky white
internal wall, thin transparent membrane, and larval head
Figure 12: Histopathology showing host capsule with duct-like
invaginations and inflammatory cell infiltrate
done as the diagnosis was confirmed by radiological
investigations.
Histopathologic examination is the gold standard for the
diagnosis of cysticercosis. Histopathologic examination
helps in the diagnosis of cysticercosis by the detection
of a cystic space containing the cysticercus cellulosae.
After a period of about 3 years, the larva dies and after
about another 2 years, the cyst undergoes calcification,
which may also be appreciated on radiographs as rice
grain type of calcifications.[11] Fine needle aspiration
cytology can also aid in diagnosis as reported in some
series, but is subject to sampling error and may fail to
confirm the diagnosis.[7]
Treatment includes medical and surgical modalities.
The management of cysticercosis is also site-dependant.
Drugs such as praziquantel (50 mg/kg/day in three
doses for 15 days) and albendazole (15 mg/kg/day
in three doses for 28 days) are potent antihelminthics
used in the treatment of cysticercosis. Praziquantel,
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Devulapalli RV et al.: Oral cysticercosis
however, has no effect on calcified parasites.[12] Since both
albendazole and praziquantel provoke inflammatory
responses, patients receiving either drug should be
hospitalized and given high doses of glucocorticoids.
Surgical excision of accessible solitary lesions is still
the “gold standard” of treatment, with no evidence of
recurrence reported.[13]
Conclusion
In spite of better diagnosis and prompt treatment,
precautions have to be taken for the prevention of
cysticercosis, which may be even fatal with unusual
complications. The major means of preventing infection
is the adequate cooking of pork, decreasing the
opportunities for ingestion of fecally derived eggs by
means of good personal hygiene, effective fecal disposal,
and treatment and prevention of human intestinal
infections.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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