Dr Harsh Mahajan and colleagues at Mahajan Imaging Centre, Fortis Flt Lt Rajan Dhall Hospital, New Delhi, India have reported a rare case of asymptomatic Disseminated Cysticercosiswhich involved the brain, face, orbit, lungs, heart, pancreas and spleen. The case has appeared in the Journal of Clinical and Diagnostic research.
Cysticercosis is a parasitic infestation which is caused by encysted larval stage of the pork tape worm, Taenia solium.It is a common problem world wide but disseminated cysticercosis is rare. Still rarer is asymptomatic disseminated cysticercosis.
A 27-years old Nigerian male presented with the chief complaint of dysphagia which had two year’s duration. The dysphagia was initially to solids, which further progressed to liquids as well. An upper GI endoscopy which was done in Nigeria revealed a distal oesophageal stricture, with no evidence of growth. The patient subsequently came to India for further treatment.
On general clinical examination, he was found to be a well-nourished individual. His vital parameters were all within normal limits. Multiple subcutaneous nodules (10-15mm) were detected all over his body. On examination of his respiratory system, bilateral basal crepitations were heard. Rest of the clinical examination was within normal limits. Routine haematological and biochemical parameters were within normal limits. His HIV ELISA test was negative.
He underwent a plain CT scan, followed by a contrast-enhanced CT scan of the chest in a 64 slice multi-detector row CT scanner (GE Healthcare, Milwaukee, WI, USA). The CT scan study revealed a moderately dilated oesophagus with an air fluid level within it. The distal oesophagus showed smooth luminal narrowing, with a thin stream of orally administered contrast, which was noted to pass into the stomach [Table/Fig-1], which was consistent with a diagnosis of achalasia cardia. The same was also confirmed on a conventional barium swallow study. Besides, there were multiple, discrete parenchymal nodules (maximum size: 10mm) which were distributed randomly in both lung fields [Table/Fig-2]. On soft tissue window setting, most of these nodules showed the presence of central fluid attenuation (HU=6 to 10) with an eccentric hyperdense (HU=45 to 55) focus which was consistent with a diagnosis of cysticercosis [Table/Fig-3]. Similar fluid attenuating nodular lesions were noted in the visualized thoracic and abdominal walls. On a closer look, at least one such lesion was also noted in the musculature of the interventricular septum [Table/Fig-4]. The visualized upper abdomen revealed the presence of similar lesions within the pancreas, spleen and possibly, in the upper pole of right kidney [Table/Fig-5 and and6].6]. In view of these findings, NCCT, followed CECT of the head were carried out, although he did not give any past history of seizures. Findings of CT scan of the head were consistent with a diagnosis of neurocysticercosis which was in vesicular stage [Table/Fig-7]. In addition, similar lesions were noted in and around the orbit as well as in facial muscles [Table/Fig-8]. Based on the CT scan findings, a diagnosis of achalasia cardia with an incidentally detected (asymptomatic) Disseminated Cysticercosis (DCC) was made. Later, he was found to be positive for anticysticercal antibodies by ELISA.
He underwent cardiomyotomy for achalasia cardia through the abdominal route. During the immediate post-operative period, he was on prophylactic antibiotics, analgesics and proton pump inhibitors (pantoprazole). He had an uneventful post-operative recovery. Although he was asymptomatic for DCC, he was treated with oral albendazole under supervision. A neurological consultation was sought and he was put on antiepileptic medication. A post- operative follow up CT oesophago-gastrography revealed good contrast opacification of the oesophagus, GE junction and stomach, with no evidence of any extra-luminal tracking or pooling of contrast. The patient was briefed about the status of DCC and he was subsequently discharged from the hospital with an advice of periodic follow ups.