Intraocular and neuro-cysticercosis with diffuse stromal choroiditis

Dipankar Das; Harsha Bhattacharjee; Kasturi Bhattacharjee; Manab Jyoti Barman; Saidul Islam; Bidhan Chandra Das; Saurabh Deshmukh; Apurba Deka; Palak Chirania; Nitu Kumari

doi:10.4103/ijpm.ijpm_258_21

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CASE REPORT

Year : 2023 | Volume : 66 | Issue : 1 | Page : 152-154

Intraocular and neuro-cysticercosis with diffuse stromal choroiditis

Dipankar Das¹, Harsha Bhattacharjee², Kasturi Bhattacharjee³, Manab Jyoti Barman⁴, Saidul Islam⁵, Bidhan Chandra Das⁶, Saurabh Deshmukh⁴, Apurba Deka⁶, Palak Chirania², Nitu Kumari²
¹ Department of Ocular Pathology, Uveitis and Neuro-Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
² Department of Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
³ Department of Oculoplasty, Cataract and Refractive Surgery, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
⁴ Department of Vitreo-Retina, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
⁵ Department of Parasitology, College of Veterinary Science, Assam Agricultural University, Khanapara, Guwahati, Assam, India
⁶ Department of Ocular Pathology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India

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Date of Submission	08-Mar-2021
Date of Decision	09-Apr-2021
Date of Acceptance	01-Jun-2021
Date of Web Publication	18-Jan-2023

Abstract

Intraocular cysticercosis with central nervous system involvement is not that rare. We report a male child with a right-sided painful blind eye who had intraocular cysticercosis and granuloma in the left frontal lobe of the brain. There was an incidental finding of chronic inflammation in the choroid of that eye supported by histopathology. Immunohistochemistry for T-cells marker and B-cells marker was variable. The patient was treated with antiparasitic, anti-epileptic medications, and oral steroids subsequently.

Keywords: Choroiditis, cysticercosis, immunohistochemistry, inflammation, pathology

How to cite this article:
Das D, Bhattacharjee H, Bhattacharjee K, Barman MJ, Islam S, Das BC, Deshmukh S, Deka A, Chirania P, Kumari N. Intraocular and neuro-cysticercosis with diffuse stromal choroiditis. Indian J Pathol Microbiol 2023;66:152-4

How to cite this URL:
Das D, Bhattacharjee H, Bhattacharjee K, Barman MJ, Islam S, Das BC, Deshmukh S, Deka A, Chirania P, Kumari N. Intraocular and neuro-cysticercosis with diffuse stromal choroiditis. Indian J Pathol Microbiol [serial online] 2023 [cited 2023 May 27];66:152-4. Available from: https://www.ijpmonline.org/text.asp?2023/66/1/152/367951

Introduction

Cysticercosis with ophthalmic manifestations can have serious health problems.^{[1],[2],[3],[4],[5]} Most of the infected individuals are young and middle-aged.^{[1],[2],[3],[4]} There were reports of intraocular cysticercosis with brain and other neurological involvement in the literature.^{[1],[2],[3],[4],[5]} Intraocular cysticercosis with diffuse choroidal inflammation was never reported earlier.^{[1],[2],[3],[4],[5]}

Case Report

A 6-year-old Asian Indian boy presented to a tertiary center of Northeast India with eye pain and redness in the right eye (OD) for 2 months. It was gradual and worsening. There was no history of trauma to the eyes.

On examination, he had a loss of perception of light in the OD and 20/30 in the left eye (OS), N 6 at 30 cm. Relative afferent pupillary defect was noted in the OD. The anterior segment in OD revealed anterior chamber quiet with posterior synechiae. Vitreous cells were +++ in OD. The OS was normal and intraocular pressure was normal in both eyes. Fundus examination in OD revealed a yellowish-colored retinal lesion in the posterior pole with retinal detachment [Figure 1]a. B-scan ultrasound in OD showed total tractional retinal detachment with gross pre-retinal as well as sub-retinal membrane echoes. A big cyst with scolex was noted in the sub-retinal area in the inferior nasal quadrant. The retino-choroid was thickened. Magnetic resonance imaging (MRI) of the brain and orbit revealed a nodular calcified lesion in the left frontoparietal region with thickening of the retino-choroidal layer in OD [Figure 1]b. A similar lesion was seen in the left basal ganglia. The impression of ultrasound and MRI suggested intraocular cysticercosis in the OD with evidence of neuro-cysticercosis and an increase in the retino-choroidal layer in the painful blind eye. While his ocular finding was very serious, there was a lack of systemic findings and he had no neurological deficit. Other investigations showed mild raised eosinophil count on complete blood examinations. Retrovirus tests, serology for hepatitis, bleeding time, clotting time, and real-time polymerase chain reaction for Coronavirus disease (COVID) were negative. After proper parental consent, enucleation with an acrylic ball implant was done in the OD. The patient was advised oral antiparasitic medications for cysticercosis and steroid. The neurologist had added anticonvulsant drugs.

Figure 1: (a) Fundus photo of the right eye showing yellowish-colored retinal cysticercus lesion in the posterior pole with retinal detachment. (b) Magnetic resonance imaging in axial view showing a T2 hyperintense lesion in the left frontal lobe of the brain involving cortical and subcortical region (arrow). Please note that a similar lesion was noted in the left basal ganglia

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The enucleated eyeball (OD) measured normally in all dimensions. Transillumination defect was not seen. The eyeball was sectioned vertically. The cut end of the optic nerve was submitted separately. A grayish white-colored cyst was seen in the vitreous cavity surrounded by whitish fibrotic structures [Figure 2]a. Retinal detachment was noted. Lateral calottes were submitted by bread loaf techniques.

Figure 2: (a) Enucleated eyeball's pupil optic nerve cut section showing a grayish white-colored cyst seen in the vitreous cavity (arrow) surrounded by whitish fibrotic structures under a laboratory dissection microscope (LEICA- S 6 D, Germany) (b) Showing thinned wall of the cysticercus cyst with convolution, extensive folding in the spiral canal, and isolated hooklet was visualized under the objective of the compound microscope (Zeiss- Axioskop 40, AxioCam MRc, Germany, H and E, 40X)

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Microscopic examination showed corneal pannus with stromal neovascularization and scarring. Descemet's membrane was normal with loss of endothelial cells. The angle of the anterior chamber was opened on both sides. The ciliary processes were elongated as seen in a young child. No crystalline lens was seen. The posterior segment revealed a dysplastic retina. Intra-retinal bone formations were noted with retinal hemorrhages. A cysticercus lesion was seen in the third calotte which showed a thinned wall of the cyst, convolution with extensive folding in the spiral canal, and an isolated hooklet was documented on the periphery of the folds [Figure 2]b. There was diffuse infiltration of the choroid with lymphocytes, plasma cells, eosinophils, and macrophages [Figure 3]. In some parts, choriocapillaris were spared by inflammatory cells. The adjoining areas showed inflammatory cells infiltrate with numerous eosinophils near the parasitic cyst. A portion of the retina showed detachment and cholesterol clefts which depicted chronicity of the disease. Intra-retinal exudation and retinal vessels were also seen. The cut end of the optic nerve was normal. Immunohistochemistry (IHC) revealed CD 3 cells (T-cell marker): ++ [Figure 4]a and CD 20 (B-cell marker): + [Figure 4]b (CELL MARQUE, USA; slides were compared with controls). He was on follow-up with a continuation of his medications.

Figure 3: Photomicrograph showing extensive and diffuse choroidal inflammation (H and E, 20X)

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Figure 4: Photomicrograph of immunohistochemistry showing (a) CD 3++ cells and (b) CD 20 + cells [CELL MARQUE, USA; slides were compared with controls] in the choroid

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Discussion

Human cysticercosis has varied manifestations.^{[1],[2],[3],[4],[5]} Intraocular and neuro-cysticercosis had been reported in a number of scientific literature and proper surgical and medical treatment had restored vision and neurological complications in many of the cases.^{[1],[3],[4],[5]}

Our case had an intraocular lesion documented by fundus photography and supported by ancillary investigations.^[1],[3],[5] Because of the painful blind eye, enucleation was done in the affected OD which revealed intraocular cysticercus lesion with incidental findings of retinal dysplasia and stromal choroidal inflammation. The inflammation consisted of lymphocytes, eosinophils, plasma cells, and a few macrophages.^[6] IHC for both T-cells and B-cells was positive. B-cell affection was also seen in this case probably due to chronicity of the disease which was correlated to histopathology by the presence of cholesterol clefts and bone formations. Interestingly, our minor patient and his attendant did not give a history of trauma or surgery in either eye of the child ruling out sympathetic ophthalmia.^[6] In infectious etiology, endoparasite which enters the eye through choroidal blood vessels may incite inflammations and result in the formation of active uveal pathology. Pathologic activation of inflammatory cells by parasites via activation of various complement (C3b, C5a), helper T-cells (Th1) which release various chemokines and cytokines like Tumor Necrosis factor (TNF), Interleukin-1(IL-1), IL6, and Interferon -gamma (IFN-gamma) may promote and recruit the inflammatory cells to incite granulomatous or non-granulomatous inflammation.^[3],[5] Cysticercosis with secondary choroidal inflammation in the same eye was never reported earlier in the PUBMED search result.^{[1],[2],[3],[4],[5]}

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent form. In the form the patient's father had given his consent for his son's images and other clinical information to be reported in the journal. The patient's attendant understand that his son's name and initial will not be published and due efforts will be made to conceal his identity.

Acknowledgments

- Sri Kanchi Sankara Health and Educational Foundation.

- Dr. Hemalata Deka MS; Dr. Jayanta Kumar Das, DO, DNB, PhD; Dr. Himanshu Kumar Talukdar, MBBS; Dr. Gayatri Bharali, MD, Mr. Pankaj Kumar Goswami, MSc.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Rathinam SR, Annamalai R, Biswas J. Intraocular parasitic infections. Ocul Immunol Inflamm 2011;19:327-36.
2.	Das D, Ramachandra V, Islam S, Bhattacharjee H, Biswas J, Koul A, et al. Update on pathology of ocular parasitic disease. Indian J Ophthalmol 2016;64:794-802. [PUBMED] [Full text]
3.	Das D, Deka S, Islam S, Deuri N, Deka P, Deka AC, et al. Neuro and intraocular cysticercosis: A clinicopathological case report. Eye Brain 2010;2:39-42.
4.	Li JJ, Zhang LW, Li H, Hu ZL. Clinical and pathological characteristics of intraocular cysticercosis. Korean J Parasitol 2013;51:223-9.
5.	Hogan MJ, Zimmerman LE. Ophthalmic Pathology: An Atlas and Textbook. 2^nd ed. Philadelphia: WB Saunders and Company; 1962. p. 487.
6.	Das D, Krishnakumar S, Biswas J. Sympathetic ophthalmia with incidental finding of chicken pox supported by histopathology and immunohistochemistry. Indian J Pathol Microbiol 2019;62:592-4. [PUBMED] [Full text]