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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 4  |  Issue : 4  |  Page : 504-508  

Importance of ultrasonography and magnetic resonance imaging in diagnosis of cysticercosis of temporalis muscle mimicking temporal space infection


1 Department of Oral Medicine and Maxillofacial Radiology, Kalka Dental College and Hospital, Meerut, India
2 Department of Oral Medicine and Maxillofacial Radiology, Teerthanker Dental College and Hospital, Mooradabad, Uttar Pradesh, India
3 Department of Oral Medicine and Maxillofacial Radiology, M. B. Kedia Dental College and Teaching Hospital, Birgunj, Nepal
4 Department of Periodontics, SGT Dental College and Research Centre, Gurgaon, Haryana, India

Date of Web Publication17-Dec-2013

Correspondence Address:
Pallak Arora
Sugandhit, 1 Pachenda Road (Near PNB), Devpuram, Muzaffar Nagar, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-237X.123059

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   Abstract 

Cysticercosis cellulosae, caused by the larval stage of Taenia solium is a common parasitic infection in Indian subcontinent. Although cysticercosis is common in other parts of the human body, its involvement with temporalis muscle is an extremely rare entity and demands documentation. This paper reports a case of cysticercosis cellulosae in a 35-year-old male patient within the temporalis muscle mimicking temporal space infection; due to the presence of concomitant dental infection, which was diagnosed with the help of high resolution ultrasonography and magnetic resonance imaging and managed conservatively using oral antiparasitic medication. Here, in this case report, we are emphasizing the importance of imaging modalities in diagnosing space infection and cysticercosis.

Keywords: Cysticercosis cellulosae, magnetic resonance imaging, space infection, temporalis, ultrasonography


How to cite this article:
Rastogi S, Arora P, Devi P, Wazir SS, Kapoor S. Importance of ultrasonography and magnetic resonance imaging in diagnosis of cysticercosis of temporalis muscle mimicking temporal space infection. Contemp Clin Dent 2013;4:504-8

How to cite this URL:
Rastogi S, Arora P, Devi P, Wazir SS, Kapoor S. Importance of ultrasonography and magnetic resonance imaging in diagnosis of cysticercosis of temporalis muscle mimicking temporal space infection. Contemp Clin Dent [serial online] 2013 [cited 2019 Oct 20];4:504-8. Available from: http://www.contempclindent.org/text.asp?2013/4/4/504/123059


   Introduction Top


Odontogenic infection comprises a high percentage of maxillofacial infections, if not controlled, can spread to adjacent head and neck fascial spaces. Fascial space infections may occasionally cause morbidity and thus use of advanced imaging in detection of space infections is helpful for the clinician for better management of fthe patient. [1]

Cysticercosis is a parasitic infection caused by Taenia solium. Cysticercus cellulosae, the larval stage of T. solium, resides in muscles and other tissues in pigs that serve as intermediate hosts. Taenia eggs may be ingested through the consumption of raw or undercooked pork, contaminated water or vegetables or by autoinfection caused by egg reflux in the stomach in people infected with adult T. solium. [2] Human beings serve as either a definitive or an intermediate host of the adult tapeworm. [3] Cysticercosis is endemic to developing countries India, Indonesia, China, Africa, Peru, Mexico, where there is poor access to sanitation facilities and close interaction between humans and animals. [4]

The ocular and cerebral locations account for 86% of diagnosed cases of human cysticercosis. The remaining 14% are in the subcutaneous, cardiac, pulmonary, muscular, hepatic and oral locations. [5] The reason for the preferential survival and growth of cysticerci in the human brain and skeletal muscle is not completely understood, but it may be related to increased blood supply in these tissues compared with other organs. [6] It is interesting to note that oral lesions of cysticercosis is a rare event. Sporadic cases of isolated muscle mass have been reported in literature without involvement of central nervous system or eyes. Intramuscular cysticercosis has non-specific manifestations and diagnosis can be difficult. High resolution ultrasonography (USG) can demonstrate the classical cyst with scolex within and is a convenient test for diagnosis. [7] We report the presence of cysticercosis involving the temporalis muscle. To the best of our knowledge, this is the 4 th case report documenting cysticercosis involving temporalis muscle.


   Case Report Top


A 35-year-old male patient reported to the Department of Oral Medicine and Radiology with the chief complaint of restricted mouth opening and heaviness on the right side of face since 1 month [Figure 1]. On examination, patient was moderately built and nourished and his vital signs were within the normal limit. He took a vegetarian diet and had no deleterious habits. Extraoral examination revealed a diffuse swelling present in the right infratemporal region measuring approximately 2 cm × 2 cm in size near the outer canthus of the eye [Figure 2]. Swelling was firm, compressible and non-tender on palpation. Overlying skin of the swelling was normal. On intraoral examination, there was grossily decayed mandibular right third molar with deep dental caries in it. It was tender, on probing percussion and palpation. Interincisal; opening was 30 mm. Based on history and clinical examination, a provisional diagnosis of masticator and predominantly temporal space infection secondary to carious mandibular right third molar was given. Radiographic examination revealed an ill-defined radiolucency in apical one-third of mandibular right third molar [Figure 3]. Antibiotic therapy was started, though patient responded to treatment there was a slight improvement in mouth opening, but the temporal swelling still persisted. We planned for high resolution USG on Toshiba Aplio XG USG unit (Japan) with 7.5 MHz linear array transducer probe, it revealed oval 5 mm sized cystic areas with eccentric echogenic nidus with in the right temporalis muscle [Figure 4]. There was mild adjacent edema, but no evidence of collection noted. Surprisingly no sign of infection in the form of cellulitis or edema were seen.
Figure 1: Restricted mouth opening

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Figure 2: Clinical picture showing swelling in the right infratemporal region

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Figure 3: Orthopantomogram showing periapical radiolucency i.r.t 48

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Figure 4: High resolution sonogram of the right temporalis muscle showing a homogenous, hypoechoic lesion with a hyperechoic scolex

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The right masseter muscle was normal since, ultrasound helps in detection of superficial fascial space infections. Magnetic resonance imaging (MRI), which is the gold standard for fascial space infections was done by HDe Signa 1.5-T unit with a dedicated coil and revealed 12 mm × 7 mm × 8 mm cystic lesion with hypointense nidus noted with in the belly of the right temporalis muscle with hyperintensity of muscle until mandibular insertion site on image suggestive of intramuscular parasitic cyst [Figure 5]. Furthermore, inflammatory changes were seen in the right masticator space prestyloid parapharyngeal space pterygomandibular fissure and right malar region subcutaneous fat suggestive of space infection [Figure 6]. With the help of USG and MRI, we came to final diagnosis of cysticercosis of the right temporalis muscle, which was an incidental finding. MRI also helped in diagnosing fascial space infection involving masticator, parapharyngeal and pterygomandibular spaces. Empirical antibiotic therapy was given and subsequently incision and drainage was done in masticator space region, 48 was extracted. Cysticercosis was managed conservatively. Patient was given albendazole 15 mg/kg body weight/day for 14 days. A repeat MRI was performed after 3 months, which showed no abnormality in the right temporal region [Figure 7].
Figure 5: Magnetic resonance imaging coronal section showing cystic lesion with nidus in superior portion of the right temporalis muscle

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Figure 6: Magnetic resonance imaging coronal section showing hyperintensity of the right perimasseteric fascial planes

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Figure 7: Post-treatment magnetic resonance imaging

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   Discussion Top


The life cycle of Platyhelminthes is characterized by different stages of development and growth requiring various hosts that can harbor the eggs, oncospheres, larvae and adults. Usually when the larvae infest the intermediate host tissue a pathological condition called cysticercosis results. [8] The ingestion of T. solium eggs happens by consumption of faecally contaminated vegetables, food, water as well as self-contamination by reflux from the intestine in to stomach or contaminated hands. Human beings acquire cysticercosis through faecal-oral contamination with T. solium eggs from tapeworm carriers. [9] Thus, vegetarians and other people who do not eat pork can acquire cysticercosis. In the present case, it may be due to ingestion through contaminated raw vegetables as the patient was vegetarian. Cysticercosis is relatively common in developing countries of Central and South America, Asia and Africa, especially in those areas with poor sanitation where humans and animals live in close contact and in those regions where inspection of meat is not strict. [10]

In spite of the high prevalence of cysticercosis in some parts of the world, oral and perioral lesions are relatively rare. The most common locations of the reported cases are shown in [Table 1]. It can be noted that the majority have been found in the tongue (44 cases), followed by buccal mucosa (24 cases), the lower lip (19 cases) and upper lip (8 cases). [10] Isolated muscular and soft-tissue involvement is even more rare disease and produce diagnostic dilemma to the clinician. [11] as in our case cysticercosis is an incidental finding which was confused with temporal space infection. Pubmed database for the last two decades was reviewed using key words temporalis, muscle, masseter, intramuscular, cysticercosis only 9 cases were found to be documented, out of which only 3 cases of cysticercosis involved temporalis muscle [Table 2].
Table 1: Case reports of oral cysticercosis


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Table 2: Imaging features of intramuscular cysticercosis reviewed in last two decades


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Diagnosis of intramuscular cysticercosis is difficult solely on a clinical basis as the manifestations are not specific and lesions may be confused with lipoma, fibroma, neurofibroma or intramuscular abscess. [12] Plain radiography rarely shows cysticerci in the active phase, but show calcified lesions in chronic phases. As plain X-ray in a patient with a solitary cyst has a poor yield, imaging modalities such as ultrasound, MRI, computed tomography are useful in diagnosing muscular cysticercosis. [17] USG is a, non-invasive, non-ionizing, sensitive and it is also quick to perform, easily repeated with minimum patient discomfort and at low cost. [18],[19] MRI is a gold standard technique extensively used for diagnosing neurocysticercosis where it can clearly show the cyst with the scolex [7] but is an expensive modality difficult to perform with claustrophobic patients. [20],[21] High resolution sonography provides all information available with MRI and more with regards to muscle pathology. Vijayaraghavan described four different sonographic patterns of muscular cysticercosis. The first type is cysticercus cyst with an inflammatory mass around it, as a result of the death of the larva. The second type is an irregular cyst with very minimal fluid on one side, indicating a leakage of fluid. The eccentric echogenic protrusion from the wall due to the scolex is not seen within the cyst. The third appearance is a large irregular collection of exudative fluid within the muscle with the typical cysticercus cyst containing the scolex, situated eccentrically within the collection. This appearance is similar to an intramuscular abscess. In all three of these types of appearances, the salient diagnostic feature is that of the cysticercus itself, which appears as an oval or round well-defined cystic lesion with an eccentric echogenic scolex in it, [4],[11] as was seen in the present case. The fourth sonographic appearance is that of calcified cysticercosis.

Drugs such as praziquantel (15-20 mg/kg bodyweight 3 times daily for 15 days) and albendazole (5 mg/kg body weight 3 times daily for 1-4 weeks) are potent antihelminthics used in the treatment of cysticercosis [5] replacing niclosamide, which was the drug of choice for the treatment of the disease for a long period. In the present case, patient was managed conservatively by albendazole. Albendazole is a benzimidazole drug that prevents polymerization of tubulin and leads to the loss of cytoplasmic microtubules in the larvae of T. solium. Comparative studies of albendazole and praziquantel in the management of patients with active neurocysticercosis indicate better results with albendazole. [17] Drugs should be used especially in cases where surgical treatment is risky or not possible as in neurocysticercosis. No treatment is required for patients with calcified tissue cysts.


   Conclusion Top


Cysticercosis in the present case is an incidental finding and we recommend that itshould be considered in the differential diagnosis of solitary swellings within the oral and maxillofacial region. We also herald the role of high resolution USG and MRI as a diagnostic tool in such cases and also suggest that localized parasitic infections like cysticercosis can be treated successfully with conservative management using oral antiparasitic medication.

 
   References Top

1.Obayashi N, Ariji Y, Goto M, Izumi M, Naitoh M, Kurita K, et al. Spread of odontogenic infection originating in the maxillary teeth: Computerized tomographic assessment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:223-31.  Back to cited text no. 1
[PUBMED]    
2.Ribeiro AC, Luvizotto MC, Soubhia AM, de Castro AL. Oral cysticercosis: Case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e56-8.  Back to cited text no. 2
[PUBMED]    
3.Kumar BD, Dave B, Meghana SM. Cysticercosis of masseter. Indian J Dent Res 2011;22:617.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Ramakrishnan P, Bahirwani S, Balaji P. Cysticercosis of the masseter. Indian J Dent Res 2012;23:436.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Mahajan D, Khurana N, Setia N. Coexistence of salivary gland cysticercosis with squamous cell carcinoma of the mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e47-50.  Back to cited text no. 5
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6.Kumar R, Singh V, Rastogi A. Cysticercosis of temporalis muscle: A case report. J Pediatr Neurol 2005;3:269-72.  Back to cited text no. 6
    
7.Gokarn A, Gokarn S, Rathod V. Ultrasonography for masseter muscle cysticercosis. Indian Pediatr 2011;48:141-3.  Back to cited text no. 7
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8.Shetty RM, Ramprasad, Kalra A, Goyal S, Shetty S, Lambade P, et al. Cysticercosis cellulosae in labial mucosa: A rare case report. J Indian Acad Oral Med Radiol 2010;22:48-50.  Back to cited text no. 8
    
9.García HH, Gonzalez AE, Evans CA, Gilman RH, Cysticercosis Working Group in Peru. Taenia solium cysticercosis. Lancet 2003;362:547-56.  Back to cited text no. 9
    
10.Delgado-Azañero WA, Mosqueda-Taylor A, Carlos-Bregni R, Del Muro-Delgado R, Díaz-Franco MA, Contreras-Vidaurre E. Oral cysticercosis: A collaborative study of 16 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:528-33.  Back to cited text no. 10
    
11.Sharma P, Neupane S, Shrestha M, Dwivedi R, Paudel K. An ultrasonographic evaluation of solitary muscular and soft tissue cysticercosis. Kathmandu Univ Med J (KUMJ) 2010;8:257-60.  Back to cited text no. 11
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12.Reddi SP, Morales MJ, Addante RR. Solitary lesion in the masseter muscle. J Oral Maxillofac Surg 2001;59:71-5.  Back to cited text no. 12
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13.Sidhu R, Nada R, Palta A, Mohan H, Suri S. Maxillofacial cysticercosis: Uncommon appearance of a common disease. J Ultrasound Med 2002;21:199-202.  Back to cited text no. 13
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14.Sethi PK, Sethi NK, Torgovnick J, Arsura E. Cysticercosis of temporalis muscle: An unusual cause of temporal headaches. A case report. J Headache Pain 2007;8:315-6.  Back to cited text no. 14
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15.Mittal A, Das D, Iyer N, Nagaraj J, Gupta M. Masseter cysticercosis: A rare case diagnosed on ultrasound. Dentomaxillofac Radiol 2008;37:113-6.  Back to cited text no. 15
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16.Kumar V, Gulati A, Mehra B. Cysticercosis of the temporalis muscle causing temporal headache in a pregnant woman. Int J Gynaecol Obstet 2011;114:79.  Back to cited text no. 16
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17.Jay A, Dhanda J, Chiodini PL, Woodrow CJ, Farthing PM, Evans J, et al. Oral cysticercosis. Br J Oral Maxillofac Surg 2007;45:331-4.  Back to cited text no. 17
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18.Bassiony M, Yang J, Abdel-Monem TM, Elmogy S, Elnagdy M. Exploration of ultrasonography in assessment of fascial space spread of odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:861-9.  Back to cited text no. 18
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19.Peleg M, Heyman Z, Ardekian L, Taicher S. The use of ultrasonography as a diagnostic tool for superficial fascial space infections. J Oral Maxillofac Surg 1998;56:1129-31.  Back to cited text no. 19
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20.Mafee M, Valvassori G, Becker M. Imaging of the Head and Neck. 2 nd ed. Stuttgart: Thieme Medical Publishers; 2004. p. 738.  Back to cited text no. 20
    
21.Karampekios S, Hesselink J. Infectious and inflammatory diseases. In: Edelman R, Hesselink J, Zaltkin M, Crues J, editors. Clinical Magnetic Resonance Imaging. 3 rd ed., Vol. 2. Philadelphia: Saunders Elsevier; 2006. p. 1248-86.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]


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