ABSTRACT: Subcutaneous cysticercosis primarily presents as multiple free-moving nodules.
These nodules are 1-2 cm in size and are deep-seated in the subcutaneous tissue. They may be painless or mildly tender. The overlying epidermal skin surface is usually normal and the nodular lesions are often clustered. Most commonly, they are seen on the trunk, upper e tremities, and face. !efinitive diagnosis of subcutaneous cysticercosis re"uires an e cisional biopsy, #hich demonstrates the cysticercus. $or uncomplicated subcutaneous nodules, treatment re"uires surgical e cision. The primary significance of subcutaneous cysticercosis is that it may indicate involvement of the central nervous system %neurocysticercosis&. CASE PRESENTATION: The patient is a 2' year-old male from (urma, #ho has been living in the )nited States for the past year. *e presented #ith a 1.+ cm tender non-erythematous subcutaneous nodule on the right cheek of the face. The lesion is slightly mobile and has been present for the past three years. The patient states that the lesion has gotten progressively larger over the past three years. ,o other lesions #ere identified else#here on his body. The clinical impression favored a cystic lesion #ith concern for a parasitic infection versus a sebaceous cyst. - local e cision of the lesion #as performed. DISCUSSION: .ysticercosis affects appro imately +/ million people #orld#ide, and is endemic in Me ico and South -merica, sub-Saharan -frica, 0ndia, and 1ast -sia. -ppro imately 1,/// ne# cases of cysticercosis are reported annually in the )nited States. 0t is a systemic illness due to dissemination of the larval form %Cysticercus cellulosae& of the pork tape#orm, Taenia solium 234. The clinical syndromes caused by Taenia solium are categorized as either neurocysticercosis %,..& or e tra-neural cysticercosis %intestinal tape#orm infection&. The most fre"uently reported locations are skin, skeletal muscle, heart, eye, and the central nervous system %.,S&. Subcutaneous cysticercosis primarily presents as multiple freely mobile nodules. These nodules are 1-2 cm in size and are deep-seated in the subcutaneous tissue 254. They may be painless or mildly tender. The overlying epidermal skin surface is usually normal and the nodular lesions are often clustered 254. Most commonly, they are seen on the trunk, upper e tremities, and face. The gross e amination findings for subcutaneous cysticercosis usually reveal a solitary cystic lesion #ith #hite-colored, solid mural nodules is presented. The differential diagnosis for subcutaneous cysticercosis includes6 lipoma, neurofibroma, epidermoid cyst, sarcoidosis, scrofula, ganglion cyst, metastatic carcinoma, and lymphadenopathy. !efinitive diagnosis of subcutaneous cysticercosis re"uires an e cisional biopsy, #hich demonstrates the cysticercus. Microscopic e amination #ill sho# the undulating laminated membranous #all of a cysticercus %the larvae of a tape#orm&, #ith associated marked inflammatory reaction against the cyst cell of cysticercus. The cyst is composed of a thick integument and an outer surface covered #ith microvilli. The tegumental cells may display degenerative changes in the inner layer of the cyst #all. The scole may or may not be found in the specimen. -dditionally, stool e amination for ova and parasites should be performed to assess for a concomitant intestinal parasite infection. The primary significance of subcutaneous cysticercosis is
that is a possible indicator of neurocysticercosis. 0n order to assess the involvement of the .,S, a .T scan of the head %#ith and #ithout contrast& should be done on all patients suspected #ith neurocysticercosis or confirmed cysticercosis at another body location. .ases of neurocysticercosis #ill demonstrate multiple calcified cysts in the brain parenchyma on .T scan. The serious pathologic findings of neurocysticercosis %,..& include6 seizures, encephalopathy, obstructive hydrocephalus, meningoencephalitis, and vascular accidents 224. .linical e pression of ,.. depends primarily on the number and location of .,S cysticerci and degree of the host immune response and resultant peri-cystic inflammation 2+4. The ingestion of encysted pork does not directly cause cysticercosis. 7ather, it produces an intestinal infection of the adult T. solium tape#orm and becomes a carrier state for the T. solium eggs. T. solium #orms may reach a length of several meters. The morphology consists of a scole #ith four suckers, and a double cro#n of prominent hooks. 8hen the adult tape#orm reaches the small intestine, the scole attaches to the intestinal mucosa and a proglottid chain gro#s. The adult tape#orm releases three to si proglottids per day, #hich bear 3/,/// to 9/,/// eggs per proglottid into the small intestine 2:4. ,early 2+/,/// eggs are passed daily into the human feces and to the environment 2:4. 0nfections #ith cysticercus larva occur after humans consume eggcontaminated food;#ater or through self-infection via the fecal-oral route. T. solium eggs are spherical and measure 3/ to :/ <m in diameter 2:4. These eggs are digested in the stomach and release oncospheres, #hich penetrate the intestinal #all and reach the bloodstream. =ncospheres develop into cysticerci in any organ or tissue 214. The cysticercus larva completes development in about 2 months. Treatment depends on the stage and number of cysts present, their location, and the patient>s clinical presentation. $or uncomplicated subcutaneous nodules, surgical e cision is sufficient. *o#ever, for symptomatic neurocysticercosis, albendazole %antiparasitic therapy& should be given in combination #ith corticosteroids and anticonvulsants to reduce inflammation surrounding the cysts and lo#er the risk of seizures 2+4. -symptomatic cysts may never lead to symptomatic disease and in many cases do not re"uire therapy 2+4. 0n addition, education of person hygiene practices and proper food handling techni"ues should be performed. 0n this case, the patient #as referred to an infectious disease specialist for further #orkup, ho#ever the patient did not return for follo#-up care and cannot be reached. $igure 16 -ssociated inflammatory infiltrate. $igure 26 )ndulating laminated membranous #all of a cysticercus %the larvae of a tape#orm&. References: 1& .ysticercosis. http6;;###.dpd.cdc.gov;dpd ;*TM?;cysticercosis.htm. 2& .hristopher M. !e@iorgio, M.!., Marco T. Medina, M.!., 7eyna !urAn, M.!., .hi
Bee, M.!., and Susan Cietsch 1scueta, M.C.*. D,eurocysticercosisE. Epilepsy Curr. 2//: MayF :%3&6 1/9G111. Cubmed 0!6 1195339. 3& @arcHa **, @onzalez -1, 1vans .-, @ilman 7*. DTaenia solium cysticercosisE. Lancet. 2//3 -ug 15F 352%I3'3&6+:9-+5. Cubmed 0!6 12I323'I. :& !avis, ?1. D,eurocysticercosisE 1merging ,eurological 0nfections edited by Co#er, . and Johnson 7T. Taylor K $rancis @roup, 2//+. 251-2'9. +& 7iley T, 8hite -.. Management of neurocysticercosis. CNS Drugs. 2//3F 19%'&6+99-I1. Cubmed 0!6 1299+1I:. 5& )thida-Tanaka -M, Sampaio M., Lelho C1, !amasceno (C, .intra M?, de Moraes -M, Banardi L. Subcutaneous and cerebral cysticercosis. J Am Acad Dermatol. 2//: $ebF +/%2 Suppl&6S1:-9. Cubmed 0!6 1:925'+'.