Q J Med 2014; 107:459–461 doi:10.1093/qjmed/hct243 Advance Access Publication 3 December 2013
Case report Intramuscular cysticercosis: starry sky appearance HUI LIU1,2*, YU-HSIANG JUAN2,3*, WEIGANG WANG1, CHANGHONG LIANG1, HAIYU ZHOU4, NITIN P. GHONGE5 and SACHIN S. SABOO2 From the 1Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, GuangZhou, GuangDong,China, 2Cardiovascular Imaging Program, Department of Medicine (Division of Cardiovascular Medicine) and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, 3Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkuo and Chang Gung University, Taoyuan, Taiwan, 4 Department of Thoracic Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, GuangZhou ,GuangDong, China and 5Department of Radiology, Indraprastha Apollo Hospitals, New Delhi, India
*Denotes that both H. Liu and Y-H. Juan contributed equally in this manuscript and are shared first authors.
Learning Point for Clinicians Cysticercosis is now seen as a global disease affecting the whole world, and clinicians should be aware of the typical clinical presentations and imaging findings of rice-like or starry sky appearance in order to avoid misdiagnosis and thereby instituting appropriate treatment.
Case presentation A 28-year-old man without significant medical history presented to our hospital for premarital health checkup. On clinical examination, several lumps were palpated in the skin of the entire body, with arms and legs predominance. No other clinical abnormalities were found, with normal neurological and opthalmological examinations. Past history revealed occasional eating of several kinds of raw meat during his stay in the rural mountainous region. Blood tests revealed normal hematocrit profile and WBC count.
Radiographs were performed which revealed numerous rice-like ovoid calcified lesions resembling starry sky appearance in the abdomen and lower extremities with lower limb predominance (Figure 1, Panel A). Considering high suspicion for parasitic infestation, magnetic resonance imaging (MRI) of the lower extremities was performed for better anatomic compartmentalization and assessment of associated possible complications. MRI revealed numerous intramuscular rice-like ovoid lesions orientated along the long axis of the muscles with hypointense signal on T1-weighted image (T1WI; Figure 1, Panel B) and fluid-like hyperintense signal on fat saturated T2-weighted image, also resembling starry sky appearance (T2WI; Figure 1, Panel B). Based on the above imaging findings, diagnosis of cysticercosis was suspected which was subsequently confirmed on the surgical excision biopsy from one of the largest T2 hyperintense lesion in the left lower limb (Figure 2, Panels A and B). Since the patient was asymptomatic, antiparasitic therapy was avoided, and patient was discharged with recommendation for clinical follow-up.
! The Author 2013. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on November 13, 2015
Address of correspondence to Weigang Wang, Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No.106, Zhongshan 2 Rd, Guangzhou, People’s Republic of China 510080. email: [email protected]
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H. Liu et al.
Downloaded from by guest on November 13, 2015
Figure 1. Multi-panel image consisting of the plain radiographs and MRI of the thighs showing distribution and characteristics imaging findings of cysticercosis. (A) Plain radiographs reveal diffuse rice-like ovoid calcifications resembling starry sky appearance seen involving the abdomen and bilateral lower limbs. (B) Coronal MRI of the thighs reveal multiple ovoid lesions with hypointense signal on T1WI and hyperintense signal on T2-weighted image with fat saturation (T2 Fat Sat) thus resembling starry sky appearance (arrows).
Discussion Cysticercosis is a disease of major concern owing to poor sanitation conditions in certain developing countries, especially in the Latin America, Asia and Africa; however, gradually increasing trend is seen in the developed countries due to increasing travel and immigrant population.1,2 Cysticercosis results from fecal-oral contamination after ingestion of the food or water contaminated with the eggs of Taenia solium parasite which were previously passed out in feces due to tapeworm infestation from oral ingestion of uncooked contaminated pork.1 The most commonly affected body sites from cysticercosis are the central nervous system
and the muscles. The muscle involvement can have varied clinical manifestations, including the myalgic pain, or feeling of mass, pseudotumor or pseudohypertrophy;1 our patient manifested clinically with palpable nodules, corresponding to the mass-like presentation. Laboratory tests such as elevated erythrocyte sedimentation rate or eosinophilia can be inconsistent,2 as seen in our patient. The diagnosis of intramuscular cysticercosis can be difficult clinically with several clinical differentials, such as common subcutaneous/ muscular neoplasms,3 infective lesions including abscess and tuberculoma or post-traumatic conditions, thus necessitating further imaging evaluation.2
Intramuscular cysticercosis
461
Figure 2. Histopathologic images from surgically excised cysticercus lesion. (A) Gross examination demonstrates a pearly white parasitic cyst (1.2 0.8 0.7 cm3) containing clear fluid with smooth surface thick wall (0.1 cm in thickness). (B) Photograph showing microscopic examination of the parasitic cyst wall with fibrocollagenous tissue and the cysticercus bladder (H & E 40X).
Conclusion In conclusion, cysticercosis is now seen globally, and clinicians should be aware of their typical clinical presentations and imaging appearance of rice-like or starry sky appearance. Conflict of interest: None declared.
References 1. Ramraje S, Bhatia V, Goel A. Solitary intramuscular cysticercosis–a report of two cases. AMJ 2011; 4:58–60. 2. Tripathy SK, Sen RK, Akkina N, Hampannavar A, Tahasildar N, Limaye R. Role of ultrasonography and magnetic resonance imaging in the diagnosis of intramuscular cysticercosis. Skeletal Radiol 2012; 41:1061–6. 3. Juan YH, Saboo SS, Tirumani SH, Khandelwal A, Shinagare AB, Ramaiya N, et al. Malignant Skin and Subcutaneous Neoplasms in Adults: Multimodality Imaging with CT, MRI and FDG PET/CT. AJR Am J Roentgenol (in press). 4. Oh JY, Kim MJ, Sohn JW, Hong SJ, Yoon YK. Asymptomatic disseminated cysticercosis in an immunocompetent patient. Korean J Intern Med 2012; 27:481–2.
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The imaging appearance of cysticercosis depends on the status of the parasites. Radiograph can depict rice-like calcifications if the cysts are calcified.4 Ultrasonography is readily available and can demonstrate the presence of eccentric echogenic scolex in the cysticercus.2 MRI is a valuable tool which can demonstrate live cysts; the typical image appearances include hypointense signal on T1WI, hyperintense signal on T2WI along the course of muscle fibers with thin rim-enhancement after intravenous gadolinium administration.2 Gadolinium was avoided in our patient as the typical radiographic and MRI appearances of cysticercus were quite suggestive and pathologic examination was subsequently planned for confirmation. The treatment of intramuscular or subcutaneous cysticercosis depends on the presence of symptoms. Treatment is only indicated if they are symptomatic from pain or local inflammation.1,2 Antiparasitic agents, such as albendazole or praziquantel,2 can be administered to hasten the involution of cysticercosis, and cortical steroids can be added to reduce the host response and inflammatory changes associated with rupture of the cysts.2
Case report Intramuscular cysticercosis: starry sky appearance HUI LIU1,2*, YU-HSIANG JUAN2,3*, WEIGANG WANG1, CHANGHONG LIANG1, HAIYU ZHOU4, NITIN P. GHONGE5 and SACHIN S. SABOO2 From the 1Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, GuangZhou, GuangDong,China, 2Cardiovascular Imaging Program, Department of Medicine (Division of Cardiovascular Medicine) and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, 3Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkuo and Chang Gung University, Taoyuan, Taiwan, 4 Department of Thoracic Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, GuangZhou ,GuangDong, China and 5Department of Radiology, Indraprastha Apollo Hospitals, New Delhi, India
*Denotes that both H. Liu and Y-H. Juan contributed equally in this manuscript and are shared first authors.
Learning Point for Clinicians Cysticercosis is now seen as a global disease affecting the whole world, and clinicians should be aware of the typical clinical presentations and imaging findings of rice-like or starry sky appearance in order to avoid misdiagnosis and thereby instituting appropriate treatment.
Case presentation A 28-year-old man without significant medical history presented to our hospital for premarital health checkup. On clinical examination, several lumps were palpated in the skin of the entire body, with arms and legs predominance. No other clinical abnormalities were found, with normal neurological and opthalmological examinations. Past history revealed occasional eating of several kinds of raw meat during his stay in the rural mountainous region. Blood tests revealed normal hematocrit profile and WBC count.
Radiographs were performed which revealed numerous rice-like ovoid calcified lesions resembling starry sky appearance in the abdomen and lower extremities with lower limb predominance (Figure 1, Panel A). Considering high suspicion for parasitic infestation, magnetic resonance imaging (MRI) of the lower extremities was performed for better anatomic compartmentalization and assessment of associated possible complications. MRI revealed numerous intramuscular rice-like ovoid lesions orientated along the long axis of the muscles with hypointense signal on T1-weighted image (T1WI; Figure 1, Panel B) and fluid-like hyperintense signal on fat saturated T2-weighted image, also resembling starry sky appearance (T2WI; Figure 1, Panel B). Based on the above imaging findings, diagnosis of cysticercosis was suspected which was subsequently confirmed on the surgical excision biopsy from one of the largest T2 hyperintense lesion in the left lower limb (Figure 2, Panels A and B). Since the patient was asymptomatic, antiparasitic therapy was avoided, and patient was discharged with recommendation for clinical follow-up.
! The Author 2013. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on November 13, 2015
Address of correspondence to Weigang Wang, Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No.106, Zhongshan 2 Rd, Guangzhou, People’s Republic of China 510080. email: [email protected]
460
H. Liu et al.
Downloaded from by guest on November 13, 2015
Figure 1. Multi-panel image consisting of the plain radiographs and MRI of the thighs showing distribution and characteristics imaging findings of cysticercosis. (A) Plain radiographs reveal diffuse rice-like ovoid calcifications resembling starry sky appearance seen involving the abdomen and bilateral lower limbs. (B) Coronal MRI of the thighs reveal multiple ovoid lesions with hypointense signal on T1WI and hyperintense signal on T2-weighted image with fat saturation (T2 Fat Sat) thus resembling starry sky appearance (arrows).
Discussion Cysticercosis is a disease of major concern owing to poor sanitation conditions in certain developing countries, especially in the Latin America, Asia and Africa; however, gradually increasing trend is seen in the developed countries due to increasing travel and immigrant population.1,2 Cysticercosis results from fecal-oral contamination after ingestion of the food or water contaminated with the eggs of Taenia solium parasite which were previously passed out in feces due to tapeworm infestation from oral ingestion of uncooked contaminated pork.1 The most commonly affected body sites from cysticercosis are the central nervous system
and the muscles. The muscle involvement can have varied clinical manifestations, including the myalgic pain, or feeling of mass, pseudotumor or pseudohypertrophy;1 our patient manifested clinically with palpable nodules, corresponding to the mass-like presentation. Laboratory tests such as elevated erythrocyte sedimentation rate or eosinophilia can be inconsistent,2 as seen in our patient. The diagnosis of intramuscular cysticercosis can be difficult clinically with several clinical differentials, such as common subcutaneous/ muscular neoplasms,3 infective lesions including abscess and tuberculoma or post-traumatic conditions, thus necessitating further imaging evaluation.2
Intramuscular cysticercosis
461
Figure 2. Histopathologic images from surgically excised cysticercus lesion. (A) Gross examination demonstrates a pearly white parasitic cyst (1.2 0.8 0.7 cm3) containing clear fluid with smooth surface thick wall (0.1 cm in thickness). (B) Photograph showing microscopic examination of the parasitic cyst wall with fibrocollagenous tissue and the cysticercus bladder (H & E 40X).
Conclusion In conclusion, cysticercosis is now seen globally, and clinicians should be aware of their typical clinical presentations and imaging appearance of rice-like or starry sky appearance. Conflict of interest: None declared.
References 1. Ramraje S, Bhatia V, Goel A. Solitary intramuscular cysticercosis–a report of two cases. AMJ 2011; 4:58–60. 2. Tripathy SK, Sen RK, Akkina N, Hampannavar A, Tahasildar N, Limaye R. Role of ultrasonography and magnetic resonance imaging in the diagnosis of intramuscular cysticercosis. Skeletal Radiol 2012; 41:1061–6. 3. Juan YH, Saboo SS, Tirumani SH, Khandelwal A, Shinagare AB, Ramaiya N, et al. Malignant Skin and Subcutaneous Neoplasms in Adults: Multimodality Imaging with CT, MRI and FDG PET/CT. AJR Am J Roentgenol (in press). 4. Oh JY, Kim MJ, Sohn JW, Hong SJ, Yoon YK. Asymptomatic disseminated cysticercosis in an immunocompetent patient. Korean J Intern Med 2012; 27:481–2.
Downloaded from by guest on November 13, 2015
The imaging appearance of cysticercosis depends on the status of the parasites. Radiograph can depict rice-like calcifications if the cysts are calcified.4 Ultrasonography is readily available and can demonstrate the presence of eccentric echogenic scolex in the cysticercus.2 MRI is a valuable tool which can demonstrate live cysts; the typical image appearances include hypointense signal on T1WI, hyperintense signal on T2WI along the course of muscle fibers with thin rim-enhancement after intravenous gadolinium administration.2 Gadolinium was avoided in our patient as the typical radiographic and MRI appearances of cysticercus were quite suggestive and pathologic examination was subsequently planned for confirmation. The treatment of intramuscular or subcutaneous cysticercosis depends on the presence of symptoms. Treatment is only indicated if they are symptomatic from pain or local inflammation.1,2 Antiparasitic agents, such as albendazole or praziquantel,2 can be administered to hasten the involution of cysticercosis, and cortical steroids can be added to reduce the host response and inflammatory changes associated with rupture of the cysts.2
