Ocular Neurocysticercosis

Clinical case presentation on Ocular Neurocysticercosis

1. CLINICAL CASE PRESENTATION MODERATORS : Prof.H.Ashraf Dr.S.M.Zakir PRESENTER: Dr. Armaan Ahmed

2. PATIENT PARTICULARS NAME: XYZ AGE/GENDER: 22 Years/Male ADDRESS: Pilakha, Aligarh OCCUPATION: Farmer

3. Chief Complaints Headache- 2 months Fever(on and off)- 2 months Diminution of vision LE- 2 months

4. HOPI According to the patient he was apparently well 2 months back when he developed headache which was sudden in onset, gradually progressive, over whole head, severe in intensity, relieved on taking medications but recurred after few hours, associated with vomiting, fever and low back pain.

5. He had 2-3 episodes of vomiting- projectile, watery content, not preceded by nausea. Fever which was unrecordable, probably moderate in intensity, relieved on taking medication.

6. Diminution of vision LE which was insidious in onset, gradually progressive and painless. There were also certain behavioural changes as noticed by family members in initial few days.

7. Treatment history- Patient consulted a local practitioner in his area where symptomatic treatment for headache and fever was given but patient was not relieved off the symptoms and therefore presented to JNMCH casualty on 15/03/19 and was admitted.

8. Negative history Trauma Abnormal movements Pain in eyes Redness Double vision Floaters Flashes of Light Distortion of Image Diurnal Variation of Fever Cough Blood in cough Contact with TB Patient Weight Loss Abdominal Pain Loose stools

9. Past history There is no history suggestive of diabetes mellitus, hypertension, tuberculosis or any other chronic illness.

10. Family history Nothing significant

11. Personal history Diet: Mixed Sleep: Initially disturbed due to headache Appetite: Normal Bowel/bladder: Regular Addiction: Nil

12. General Examination Patient was cooperative at the time of examination Well oriented to time, place and person Vitals- Pulse rate- 92/min Blood pressure- 122/72 mm hg Respiratory rate- 18/min Temperature- Afebrile Multiple lymph nodes present on right side of neck

13. Systemic Examination CNS: Higher functions intact, cranial nerves intact, no sensory motor deficit. CVS: S1 S2 normal, no murmur Respiratory System: Normal vesicular breathing, no added sounds. Per Abdomen: Soft, non tender, no organomegaly

14. Diffuse Light Examination Head posture- Normal Forehead - Normal Facial symmetry- Maintained Eye brows- Normal Eye lids- Normal Ocular movements- Full in all gazes (BE) HBCR - Central (BE)

15. Visual acuity: (BCVA) RE: +0.50 DS +0.50 DC 135 6/6 LE: +0.5 DS +1.00 DC 75 6/9 NCT : RE: 13 mm Hg LE: 12 mm Hg

16. Slit Lamp Examination RE UPPER LID Normal LOWER LID Normal CONJUNCTIVA Normal CORNEA Clear AC Quiet and normal depth IRIS Normal colour and pattern PUPIL Normal size normal reacting LENS Clear

17. Slit Lamp Examination LE UPPER LID Normal LOWER LID Normal CONJUNCTIVA Normal CORNEA Clear AC Quiet and normal depth IRIS Normal colour and pattern PUPIL RAPD Grade 2 LENS Clear

18. FUNDUS RE Red glow Present Media Clear Disc- Margin Blurred Circumferentially Colour Hyperemic Size,shape,C:D ratio Cannot be commented upon Blood vessels Arteriolar attenuation, tortuous vessels Background Large haemorrhage seen inferonasal to disc myelinated nerve fibre layer seen Macula Healthy Foveal reflex Present

19. FUNDUS LE

20. FUNDUS LE Red glow Present Media Clear Disc -Margin Blurred Circumferentially Colour Hyperemic Size ,shape C:D ratio Cannot be commented upon Blood vessels Arteriolar attenuation, tortuous vessels Background Large cystic lesion present inferonasally and in nasal part of retina with scolex with pigmentation. Undulating movement of cyst seen with exudative retinal detachment present inferiorly and nasally. A trophic chorioretinal patch present in superonasal part of retina. Macula Macular pucker present sparing the foveal region Foveal reflex Present

21. Investigations done CBC - RBCs are microcytic to normocytic with mild hypochromia TLC- 10,000/microlitre DLC few PMNs show toxic granules PLATELET adequate by smear Hb 10.4 g/dl AEC 100 cells/mm3 MPQBC –Negative TRIPLE TEST- Non reactive

22. RFT - Blood urea-24 mg/dl Serum creatinine-0.82 mg/dl Blood sugar-62 mg/dl Sodium- 135 mmol/l Potassium- 4.4 mmol/l LFT – SGOT- 9 I.U/L SGPT- 12 I.U/L BILIRUBIN TOTAL- 0.7 MG/100 ML STOOL EXAMINATION for cyst,ova,occult blood,pus cells -negative

23. USG ABDOMEN- shows multiple well defined lesions with hyper echoic centre with no internal vascularity in muscular plane of anterior abdominal wall. (suggestive of anterior abdominal wall myocysticercosis) X RAY CHEST- WNL

24. CT SCAN Multiple variable sized intra-axial hyper densities distributed in brain parenchyma with no surrounding oedema. Well defined intra-axial hyper densities with a CT value of CSF in both lobes of cerebral hemisphere.

25. Treatment advised Inj ceftriaxone 1g iv BD Inj dexamethasone (8mg) iv TDS Inj mannitol 20 units in 100 ml TDS Inj pantoprazole 40 mg iv OD Inj ondansetron 4 ml iv TDS Tab tramadol hydrochloride(37.5mg) and acetaminophen(325mg) sos Tab praziquantal 1g TDS Tab albendazole 400 mg BD

26. 2 doses of albendazole and praziquantal were given, then it was withdrawn after ophthalmic consultation.

27. Treatment advised from our side (19/03/19) Tab prednisolone 60 mg OD P/C Tab pantoprazole 40mg OD BBF Surgery advised- vitrectomy with scleral buckling with excision of subretinal cyst with PFCL air exchange with silicone oil with endolaser (LE) (planned on 23/03/19)

28. On table cyst within inferior rectus muscle was also identified and excised along with vitrectomy with scleral buckling with subretinal cyst excision with silicone oil with endolaser (LE)

29. Post op advice- Eye patched for 48 hours Tablet ciplox 750 mg 1 tab BD

30. INFERIOR RECTUS CYST SUBRETINAL CYST

31. Provisional diagnosis Orbital (inferior rectus) cysticercosis with ocular (subretinal) cysticercosis with cysticercosis of brain and anterior abdominal wall with exudative retinal detachment.

32. Post op (26/03/19) Visual acuity(BCVA)- RE +1.00 DS +0.50 DC 90 6/9 LE +2.50 DS +1.50 DC 75 6/36 NCT- RE 17 mm Hg LE 13 mm Hg

33. ADVICE - E/D Mosi-d (moxifloxacin-0.5% + dexamethasone 0.1%) LE QID Steroid and antihelminthic therapy is to be started after 7 days

34. THANK YOU