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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 14  |  Issue : 4  |  Page : 391-393

Subcutaneous cysticercosis: Imaging findings on sonography and elastography


Department of Radio Diagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission29-Nov-2019
Date of Decision08-Dec-2019
Date of Acceptance15-Dec-2019
Date of Web Publication16-Jul-2020

Correspondence Address:
Dr. Suresh Phatak
Department of Radio-diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_197_19

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  Abstract 


Cysticercosis is a disease caused by cysticercus cellulosae, a larval form of tapeworm, Taenia solium. A 35-year-old male presented with seizures and multiple subcutaneous nodules all over his body, which was diagnosed to be a case of disseminated neurocysticercosis on ultrasonography and was confirmed on brain magnetic resonance imaging. High-resolution sonography and elastography findings are discussed.

Keywords: Elastography, high-resolution sonography, musculoskeletal cysticercosis


How to cite this article:
Singh V, Phatak S, Samad S, Marfani G. Subcutaneous cysticercosis: Imaging findings on sonography and elastography. J Datta Meghe Inst Med Sci Univ 2019;14:391-3

How to cite this URL:
Singh V, Phatak S, Samad S, Marfani G. Subcutaneous cysticercosis: Imaging findings on sonography and elastography. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 13];14:391-3. Available from: http://www.journaldmims.com/text.asp?2019/14/4/391/289851




  Introduction Top


Cysticercosis caused by Taenia solium is commonly found in people eating uncooked pork and other meat product. It is found to be endemic in Mexico, Central and South America, Asia, India, Sub-Saharan Africa, and China. Cysticercosis can affect various organs, including the brain, spinal cord, orbit, muscle, subcutaneous tissue, and heart.[1] Isolated involvement of skeletal muscles and subcutaneous tissue is very rare and it is generally accompanied with neurological involvement. The symptoms vary in accordance with the site of involvement. In this day and age, ultrasonography (USG), being nonionizing and noninvasive, plays an important role in the diagnosis of subcutaneous and muscular cysticercosis. If the subcutaneous or muscular lesion with morphological characteristics of cysticercosis is found, no further investigations are required.[2]


  Case Report Top


A 35-year-old male patient came with complaints of two episodes of seizures in the past 1 year, headache which was off and on for the last 1 month. He also complained of subcutaneous nodules, which was initially only present over the anterior abdominal wall on the right side. Over the last 6 months, he has developed more such subcutaneous nodules over the right nipple region, medial aspect of the thigh, right paraspinal region, and left infraclavicular region.

Investigations

The patient underwent blood and renal and liver function tests which were normal at presentation. This was followed by USG of the local site lesions. The USG revealed multiple well-encapsulated hypoechoic lesions with central echogenic nodules showing “cyst with dot sign” in the subcutaneous plane, located in the right paraspinal region, lower anterior abdominal wall, right nipple area, the left infraclavicular region, and on the medial aspect of the right thigh measuring 11.5 mm × 5.8 mm, 10 mm × 6 mm, 8.3 mm × 6.8 mm, 10 mm × 6 mm, and 6.8 mm × 5 mm, respectively, suggestive of subcutaneous cysticercosis [Figure 1] and [Figure 2]. The lesions did not show much vascularity on Doppler. Elastography finding revealed blue–green–red (BGR) appearance of a cystic lesion with small strain ratio (SR), indicating benign nature of the lesion [Figure 3]. Following which the patient was referred for an magnetic resonance imaging (MRI) brain, which revealed multiple well-defined ring-enhancing lesions throughout the brain parenchyma appearing hyperintense on T2, hypointense on T1, and fluid-attenuated inversion recovery with no restriction on diffusion-weighted imaging and blooming on gradient recalled echo. There was e/o hyperintense foci noted within the cyst which s/o scolex. Hence, MRI confirmed it to be a case of disseminated cysticercosis [Figure 4].
Figure 1: Encapsulated hypoechoic lesions with central echogenic nodules showing “cyst with dot sign” in the subcutaneous plane

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Figure 2: Eencapsulated hypoechoic lesions with central echogenic nodules showing “cyst with dot sign” in the subcutaneous plane

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Figure 3: Elastography shows blue–green–red appearance typical of a cystic lesion with a strain ratio of 1.93 indicating benign nature of the lesion

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Figure 4: T2WI and T2 fluid-attenuated inversion recovery showing multiple cystic lesions with central hyperintense nodule s/o scolex within the cyst

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Ethical clearance

Ethical clearance was obtained from the Institutional Ethical Committee of JNMC, Sawangi (Meghe), Wardha, on 7th March 2019. With ethical clearance no DMIMS(DU)/IEC/2019-20/309.


  Discussion Top


Cysticercosis caused by Taenia solium, a tape worm, is generally seen in people who consume undercooked pork; humans are the definitive host carrying the adult tapeworm and excretes cysts and proglottides. Normally, pigs are the intermediate host; they ingest the fecal cysts; these cysts develop into the embryo, which penetrates the mucosa of the gastrointestinal tract and hematogenously disseminates to the peripheral tissues following which they develop into the larva completing the lifecycle. Human cysticercosis occurs when eggs contaminate the water and vegetables grown under the soil. When humans ingest the contaminated water and vegetables, they are termed as the accidental intermediate host, which is followed by the development of cysticercosis within the various organs.[3]

Plain radiographs rarely show cysticercosis unless the cysticerci are degenerated and get calcified. Computed tomography scan is only useful in the neurocysticercosis but not much beneficial in the musculoskeletal cysticercosis. High-frequency USG has become relatively inexpensive and is a readily available and reliable diagnostic modality for the diagnosis of soft-tissue cysticercosis. There are many reports, in which cysticercosis had been accurately diagnosed by ultrasound without the requirement of invasive techniques such as fine-needle aspiration cytology and biopsy. Four different sonographic findings have been described: the first is cysticercus cyst with an inflammatory mass around it, as a result of death of larvae; the second is an irregular cyst with very minimal fluid on one side indicating leakage of fluid; the third is large irregular collection of exudative fluid within the muscle, with the typical cysticercus cyst containing the scolex situated eccentrically within the collection; and the fourth is the appearance of calcified cyst appearing as multiple elliptical calcifications in soft tissue.[3]

Tsukuba scoring system is used in elastography; a score of 1 indicated even strain for the entire hypoechoic lesion (i.e., the entire lesion was evenly shaded in green). A score of 2 means strain in most of the hypoechoic lesion, with some areas of no strain (i.e., the hypoechoic lesion had a mosaic pattern of green and blue). A score of 3 implies strain at the periphery of the hypoechoic lesion, with sparing of the center of the lesion (i.e., the peripheral part of lesion was green, and the central part was blue). A score of 4 shows no strain in the entire hypoechoic lesion (i.e., the entire lesion was blue, but its surrounding area was not included). A score of 5 indicated no strain in the entire hypoechoic lesion or in the surrounding area (i.e., both the entire hypoechoic lesion and its surrounding area were blue). BGR represents typical artifactual three-layered aspect (BGR) encountered with cystic lesions. In strain patterns, scores of 1, 2, and 3 emphasized benign features whereas masses with scores of 4 and 5 were considered as malignant.[4] SR measurement is a semiquantitative method of lesion assessment, termed as SR measurement, has also been developed. Calculation of the SR value is based on determining the average strain measured in a lesion and comparing it to the average strain of a similar area of fatty tissue in the adjacent breast tissue. Using proprietary software, the average strain of the lesion is determined by selecting a region of interest encompassing the lesion; the value of SR increases as a function of the relative stiffness of the target lesion. As the SR increases, the likelihood of cancer also increases.[5]

The main advantage of MRI is its higher contrast resolution, which makes for better lesion conspicuity. This higher resolution is particularly helpful in the evaluation of neurocysticercosis with ventricular involvement and the detection of inflammatory changes in the musculoskeletal cysts. Cyst signal intensity is similar to that of cerebrospinal fluid on T1- and T2-weighted images; cyst wall is well defined and thin, with little or no enhancement on gadolinium-enhanced images, scolex (hole with dot appearance).[6],[7],[8],[9],[10],[11]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Naik D, Srinath M, Kumar A. Soft tissue cysticercosis – Ultrasonographic spectrum of the disease. Indian J Radiol Imaging 2011;21:60-2.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Asrani A, Morani A. Primary sonographic diagnosis of disseminated muscular cysticercosis. J Ultrasound Med 2004;23:1245-8.  Back to cited text no. 2
    
3.
Marasini RP, Thapa PB, Gautam P. Solitary intramuscular cysticercosis: A rare pseudotumour. A report of two cases. J Chitwan Med Coll 2015;5:42-5.  Back to cited text no. 3
    
4.
Itoh A, Ueno E, Tohno E, Kamma H, Takahashi H, Shiina T, et al. Breast disease: Clinical application of US elastography for diagnosis. Radiology 2006;239:341-50.  Back to cited text no. 4
    
5.
Zhi H, Xiao XY, Yang HY, Wen YL, Ou B, Luo BM, et al. Semi-quantitating stiffness of breast solid lesions in ultrasonic elastography. Acad Radiol 2008;15:1347-53.  Back to cited text no. 5
    
6.
Lohra S, Barve S, Lohra P, Nanda S, Nalwa N, Sharma P. Subcutaneous cysticercosis: Role of high resolution ultrasound in diagnosis. Natl J Med Res 2014;4:82-6.  Back to cited text no. 6
    
7.
Phatak S, Marfani G. Galactocele Ultrasonography and Elastography Imaging with Pathological Correlation. J Datta Meghe Inst Med Sci Univ 2018;13:1-3. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_51_18. [Last accessed on 2019 Oct 19].  Back to cited text no. 7
    
8.
Samad S, Phatak S. Bilateral Axillary Accessory Breast with Ductal Ectasia: Ultrasonography and Elastographic Appearance. J Datta Meghe Inst Med Sci Univ 2018;13:206-8. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_54_18. [Last accessed on 2019 Oct 19].  Back to cited text no. 8
    
9.
Chaudhary KS, Phatak SV. Choroidal Melanoma in a Young Patient Ultrasonography and Magnetic Resonance Imaging. J Datta Meghe Inst Med Sci Univ 2019;14:106-8. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_48_18. [Last accessed on 2019 Oct 19].  Back to cited text no. 9
    
10.
Gulve SS, Phatak SV. Parathyroid Adenoma: Ultrasonography, Doppler, and Elastography Imaging. J Datta Meghe Inst Med Sci Univ 2019;14:47-9. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_91_18. [Last accessed on 2019 Oct 19].  Back to cited text no. 10
    
11.
Madurwar KA, Phatak SV. Benign Fibrous Histiocytoma of Male Breast: Ultrasonography, Doppler, and Elastography Imaging with Pathological Correlation. J Datta Meghe Inst Med Sci Univ 2019;14:103-5. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_44_18. [Last accessed on 2019 Oct 19].  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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