Abstract
Cysticercus cellulosae is the larval form of Taenia solium. The disease is transmitted by faecoral route by consumption of eggs from contaminated food. Sonography & CT neck—well-defined, cystic lesion with hyperechoic area suggestive of a scolex. FNAC revealed non human like cells, fibrillation stroma, inflammatory cells. Treatment includes antiparasitic therapy, steroids.
Keywords: Extra neural cysticercosis, Scolex, Cysticercus neck swelling, Intramuscular cysticerci
Introduction
Cysticercosis is a parasitic infection caused by Cysticercus cellulosae, the larval form of Taenia solium. Humans are definitive hosts for Taenia solium; pigs and wild hogs are intermediate hosts, but humans can manifest the sporadic larval form. Cysticercosis is clinically characterized by the presence of solitary or multiple submucosal/cutaneous firm nodules, which are circumscribed, movable, usually asymptomatic [1]. Soft tissue cysticercosis lesions are usually described with neurological,ocular or hepatic involvement. There have been reports of a few cases of isolated intramuscular cysticercosis [2]
The head and neck regions commonly affected are tongue, sternocleidomastoid, masseter and strap muscles of the neck. Isolated cases of cysticercosis have been reported in the head and neck region which presents as soft tissue mass in submental area, cheek and intra orally in the lips, buccal mucosa and tongue.
Case Report
We present a case report of an isolated solitary cysticercus neck swelling.
A 33-year-old young lady presented with symptoms of left neck swelling in the submandibular region since 2–3 weeks. The swelling was painless, progressively increased in size,noticed change in size during meals.Diet is predominantly nonvegetarian with pork consumption almost on a daily basis.
Examination revealed swelling in the left submandibular triangle of neck, oval shaped, measuring about 1 cm * 0.5 cms. Skin over the swelling appeared normal. On Palpation a mobile, firmly cystic in consistency tender, non fluctuant swelling noted.
Otorhinolaryngological examination was normal. Radiological work up included Ultrasonography neck, CT neck, CT Brain and ultrasonography of abdomen to rule out neurogenic or hepatic cysticerci.
Ultrasonography neck showed cystic lesion in the submandibular region measuring 12 mm*, 5 mm *1.9 mm in depth with calcific densities and associated peripheral vascularity.
CT neck showed a partially calcified small nodular density about 7*8 mm lesion just inferior to the submandibular gland, superficial in close proximity to platysma involving left mylohyoid muscle with inflammatory changes.
USG guided FNAC neck suggestive of fibrillation stroma showing non human nuclei,acute inflammatory cells and epitheloid histiocytes raising suspicion of cysticercosis. CT brain and USG abdomen was normal.
Treatment started with tablet albendazole 400 mg once a day for 3 weeks. Follow up done every week to assess the progess for a total period of 3 weeks with complete resolution (Figs. 1 and 2).
Fig. 1.
CT images showing cysticerci in left submandibular region
Fig. 2.
FNAC IMAGE showing fibrillation stroma, inflammatory cells
Discussion
It commonly affects the young adults between 3rd and 4th decade of life [3].
Intramuscular cysticercosis was reported in majority with the disseminated form of the disease. Hence, it warrants investigation to rule out neurological and ocular involvement. In the muscular type—three different clinical manifestations described are the (1) myalgic type/mass-like, (2) pseudotumor/abscess-like type, (3) pseudohypertrophic type. Symptoms like redness, swelling, or pain may be observed after death or degeneration of the parasite with leakage of the antigens and cellular response of the body [2].
Oral cysticercosis was considered to be unusual. researchers found a greater incidence in the tongue, followed by labial mucosa and buccal mucosa [1].
Ultrasound is a cost effective, sensitive, specific and non-invasive diagnostic tool to diagnose the extracranial cysticercosis. Sonography shows a well-defined, elliptical fluid filled cystic lesion with hyperechoic area within it suggestive of a scolex.
The detection of a cystic space containing the cysticercus cellulose is a diagnostic feature on histopathological examination. Tissue diagnosis is not essential to start the treatment. Medical therapy in form of oral albendazole and corticosteroids show remarkable improvement [4].
Fine-needle aspiration cytology is considered a diagnostic tool for soft tissue cysticercosis.The spectrum cover an entire range from viable cysts to necrotic or calcified cystic swellings.Aspiration of granular fluid is strongly suggestive of cysticercosis [5].
Intramuscular cysticerci can have variable symptoms—inflammatory mass around the swelling, a large irregular collection of fluid within the muscle, with the typical cysticercus cyst containing the scolex situated eccentrically confusing with an intramuscular abscess, a cyst without scolex (might escape outside the cyst), partially collapsed cyst or a calcified cyst. Radiograph can depict multiple calcifications in the muscles or subcutaneous tissues if the cysts are calcified [2].
Cysticercosis is treatment albendazole at 400 mg for 7 consecutive days for upto 21 days have also been used. Steroids should be added to avoid an untoward anaphylactic reaction due to the massive release of larval antigen.
Conclusion
Cysticercosis of the neck although a rare entity, it’s incidence cannot be ruled out in endemic countries unless anticipated. It must be considered as a different diagnosis to start timely treatment for better outcomes.
Footnotes
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