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Year : 2014 | Volume : 2 | Issue : 2 | Page : 111 - 112  


Case Reports
Cysticercosis in the Axillary Region: A Case Report

Sudhir Kumar Vujhini1, Panduranga Rao Sanagapati 2, Mahesh Kandukuri 3

1Assistant Professor, 2Professor and Head, Department of Transfusion Medicine and Immunohematology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India.

3Assistant Professor, Department of Pathology, MRIMS, Hyderabad, Telangana, India

 

Abstract:

Cysticercosis, a systemic illness and a major public health problem is caused by dissemination of the larval form of the pork tapeworm, Taenia solium. A high prevalence has been reported from the developing countries because of the co-existence of poor sanitary conditions and domestic pig raising. Cysticercosis is a preventable faeco-oral transmitted infection and it is possible to prevent infection by avoiding undercooked food, and water contaminated with human faeces.

In this unusual form of infection man becomes the intermediate host. The skeletal muscle, subcutaneous tissue, the eyes and CNS are the most frequently affected tissues. Other reported sites are heart, lungs, peritoneum, kidney, liver, and pancreas. The involvement of axillary region, although not unusual is a rare. We present a case of axillary cysticercosis in an 18 year old female.

Key words: Cysticercosis, Taenia solium, Axilla.

Corresponding Author: Dr. Sudhir Kumar Vujhini, Plot no-292, Lakshmisai Meadows, Beeramguda, RamachandraPuram, Hyderabad. 502032. Email: Vujhini07@yahoo.com

Introduction:

Cysticercosis is a disease caused by Cysticercus cellulosae, the larval form of tapeworm, Taenia solium. Cysticercosis is endemic in most of the developing countries like Brazil, Mexico, Korea and South Asian countries. [1] The parasite has a strong predilection to involve central nervous system (CNS). Solitary muscular and soft tissue involvement without central nervous system involvement is rare and often presents a diagnostic challenge. Imaging plays an important role in establishing the diagnosis by demonstrating a scolex on MRI and/or ultrasound. Herein we report a case of an isolated axillary cysticercosis for its rare site posing a diagnostic challenge.

Case report:

18-year-old female presented with a history of gradually progressive lump in the right axillary region for the past two months duration. On physical examination, an oval 1.5x1 cm mass was palpable which was firm, freely mobile and slightly tender in the right anterior axillary region. The skin overlying the swelling was normal. There was no history of fever or trauma. A clinical diagnosis of axillary fibroadenoma was suspected and routine investigations were advised along with ultrasound scan and FNAC. All the routine investigations were normal. Ultrasound scan revealed a well defined cystic lesion measuring 10x 8 mm in the anterior axillary (pectoralis) muscle with pericystic inflammation suggesting the possibility of cysticercosis.

FNAC was performed with five ml syringe and a scanty clear fluid was aspirated which was smeared over the slides, alcohol fixed and stained with Hematoxylin and Eosin. Smears revealed few neutrophils, macrophages and occasional eosinophils over a thin clear background suggesting inflammatory pathology ruling out clinical diagnosis of fibroadenoma.

Later, the mass was excised and sent for histological evaluation. Grossly, the mass was grey brown with focal yellowish fatty areas measuring 1.5x1.5x1.1 cm3. Histology showed parasitic cyst wall with scolex and pericystic inflammation within the skeletal muscle suggesting the diagnosis of cysticercosis (Figure 1).

Figure 1: Section showing scolex with parasitic cyst wall and surrounded by inflammation (Arrow). H and E stain x400.

Discussion:

Cysticercosis is a parasitic infection caused by Cysticercus cellulosae, the larval form of Taenia solium where as the infestation of human intestine with adult tapeworms is known as taeniasis. Humans are the only definitive host while both humans and pigs can act as intermediate hosts. The mode of transmission is feco-oral, the most common being the consumption of raw or undercooked beef or pork, water, or vegetables contaminated with Taenia eggs. [2] The skeletal muscle, subcutaneous tissue, the eyes and CNS are the most frequently affected tissues. Other reported sites are heart, lungs, peritoneum, kidney, liver, and pancreas. Children are commonly affected because of increased chances of fomite infection.

The larvae get established in the tissues as fluid-filled cysts thereby evading the immune response of the host. The intramuscular and subcutaneous cysticercosis is seen most commonly over the arms and chest and is characterized by multiple, mobile, firm, subcutaneous nodules with normal overlying skin. The nodules vary in size from 1 to 2 cm and are usually asymptomatic. It may be painful in about 20% of the patients and there are chances of abscess formation as well. The differential diagnosis includes lipomas, epidermoid cysts, neuroma, neurofibromas, pseudoganglia, sarcoma, myxoma or tuberculous lymphadenitis. [3] Solitary muscular and soft tissue cysticercal involvement is a rare disease per se and it has been used as a marker of neurocysticercosis. Therefore, central nervous system or ocular involvement should be ruled out if systemic involvement is suspected.

Diagnosis of intramuscular cysticercosis is quite difficult as lipoma, fibroma, abscess can present with similar findings. Ultrasonographic features are presence of an oval or rounded cystic lesion with well defined margin and an echogenic eccentric focus. During the death of the larva, there is leakage of fluid from the cyst. [4] The resulting acute inflammation may result in local pain and myalgia. Alternatively, degeneration of the cyst may result in intermittent leakage of fluid eliciting a chronic inflammatory response, with collection of fluid around the cyst, resulting in the mass like, pseudo tumor, or abscess.

FNAC may be diagnostic when the parasitic fragments [5] are seen in the smears. But most of the time, FNAC is inconclusive with just presence of few inflammatory cells as in our case.

Histology shows the tegument of the parasite which appears as rounded wavy folds and scolex with hooklets with hyaline membrane surrounding it. The inflammatory reaction consists mainly of eosinophils with varying proportions of other polymorphs and epithelioid cells and giant cells.

 

Conclusion:

Axillary cysticercosis is rare and poses a diagnostic challenge clinically. Early diagnosis helps to initiate appropriate therapy with cestocidal drugs, like pranziquantel or albendazol.

References:

  1. Alsina GA, Johnson JP, McBride DQ, et al. Spinal neurocysticercosis. Neurosurg Focus 2002; 12:1-7.
  2. Gupta MK, Ahmad K, Ansari S, Rauniyar RK, Choudhary S. Isolated cysticercosis of anterior abdominal wall mimicking clinically as acute appendicitis: an unusual presentation. Journal of Universal College of Medical Sciences. 2013;1(4):45-7.
  3. Khan RA, Wahab S, Chana RS. A Rare Cause of Solitary Abdominal Wall Lesion. Iran J Pediatr. Sep 2008;18(3):291-2.
  4. Roy B, Mondal Cysticercosis in Anterior Abdominal Wall: A rare case report. Bangladesh Journal of Medical Science. 2012;11(3):221.
  5. Khurana N, Jain S. Cytomorphological spectrum of cysticercosis - a review of 132 cases. Indian J Pathol Microbiol. 1999; 42: 69-71.

 

Source of Support: Nil. Conflict of Interest: None.

 

 

 

                                      

 

Cite this article as: Sudhir Kumar V, Panduranga Rao S, Mahesh K. Cysticercosis in the Axillary Region: A Case Report. MRIMS J Health Sciences 2014;2(2):111-112.

 

 

 

 

 

 

                                               





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