British Journal of Radiology (2007) 80, e58-e60
© 2007 British Institute of Radiology
doi: 10.1259/bjr/43104295
Pulmonary and cardiac cysticercosis: helical CT findings
A L Bastos, MD
1
E Marchiori, MD, PhD
3
E L Gasparetto, MD, PhD
4
B H Andrade, MD
2
G C Junior, MD
2
R C Carvalho, MD
2
D L Escuissato, MD, PhD
4 and
A S Souza, , MD, PhD
5
Departments of 1 Radiology and 2 Pneumology, Hospital Julia Kubitschek, Belo Horizonte, 3 Department of Radiology, University Fluminense and of Rio de Janeiro, Rio de Janeiro, 4 University of Paraná, Curitiba, 5 School of Medicine of São José do Rio Preto, São José do Rio Preto, Brazil
Correspondence: Emerson L Gasparetto, R. Capote Valente 500 ap. 2215, 05409-000, São Paulo, SP, Brazil. E-mail: egasparetto{at}gmail.com.
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Abstract
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The authors aim to report the chest CT findings of a patient with disseminated cysticercosis, emphasising the pulmonary and cardiac features. The main finding consisted of multiple pulmonary, cardiac and chest wall nodules. The present case demonstrates that cysticercosis should be considered in the differential diagnosis of multiple pulmonary nodules, mainly in those patients with similar lesions in the cardiac muscle and/or in the chest wall.
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Introduction
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Cysticercosis, which is acquired by ingestion of ova of the tapeworm Taenia solium, is a common parasitic disease in endemic regions such as Latin America. The disease may affect any organ of the body, although central nervous system manifestations are the most commonly reported [1]. Because of globalization, many clinicians in industrialized countries who are unfamiliar with cysticercosis are now faced with this disease [2], owing to immigration of tapeworm carriers from endemic zones [2, 3].
Although the chest radiographic findings of patients with pulmonary cysticercosis have been described, previously there are rare reports of the CT scan features in these patients [4, 5]. In addition, to our knowledge, there are no previous studies demonstrating the CT findings of the association of pulmonary, cardiac and chest wall cysticercosis.
The authors aim to report the chest radiographs and CT findings of a patient with disseminated cysticercosis, emphasising the pulmonary and cardiac involvement.
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Case report
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A 39-year-old male rural worker presented with a 6 month history of dyspnoea and progressive low visual acuity at the left side. He also referred to seizures since childhood, which were controlled with anticonvulsive medication. The physical examination showed multiple subcutaneous nodules, which were predominant in the arms and thorax. The lung auscultation was normal.
All the laboratory investigations were normal. The chest radiographs showed multiple pulmonary nodules, which had regular contours and were 10 mm in diameter (Figure 1
). The chest CT demonstrated the same aspect, with multiple well defined random nodules with an average size of 10 mm in diameter (Figure 2). The chest wall and cardiac musculature also presented hypodense nodules, some of them with punctiform central hyperattenuation (Figure 3). In addition, the head CT scan demonstrated multiple ring-like enhancing brain nodules and one nodule compressing the left optic nerve.
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Figure 2. Helical CT scan with lung parenchyma window shows multiple random nodules with average size of 10 mm, which present regular contours.
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Figure 3. Helical CT scan(after contrast administration) with mediastinal window demonstrates hypoattenuating nodules in (a) the cardiac muscle (white arrows), (b) chest wall and right scapular region. Some of these nodules present a central punctiform hyperattenuation (black arrow), which represents the scolex.
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The fibroscopy with bronchoalveolar lavage was negative to fungi, tuberculosis and neoplastic cells. An excisional biopsy of a subcutaneous nodule was performed, and the histological examination confirmed the diagnosis of cysticercosis. The patient was treated with albendazole and 2 months later the chest radiographs were normal, the visual acuity improved and most of the subcutaneous nodules disappeared.
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Discussion
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Cysticercosis refers to the larval form of infection of Taenia solium, a pork tapeworm. The disease is prevalent in South America, Mexico, Africa, India and China [3, 6, 7]. Also, it is becoming increasingly recognized in industrialized countries, because of immigration from countries where the infection is endemic [2]. The cysticercosis occurs when man ingests viable eggs in food or water contaminated by carriers of the adult pork tapeworm, or by autoinfection in patients harbouring the adult worm in their intestines [3, 5–8].
The Taenia solium has a complex two-host life cycle. Humans are the only definitive host and harbour the adult tapeworm, whereas both humans and pigs may act as intermediate hosts and harbour the larvae or cysticerci [3, 5]. In the small bowel, the ingested ova give rise to an embryo, which penetrates the wall of the intestine, enters the bloodstream and arrests anywhere in the body [5–7]. Once it reaches a small terminal vessel, the embryo establishes and encysts to form the larval vesicles or cysticerci, reaching the definitive size of 1–2 cm in 2–3 months [5].
The clinical symptoms of cysticercosis are protean and basically reflect compromise of the affected organs [3, 4]. Disseminated cysticercosis mainly involves the central nervous system, and occasionally striated muscles and subcutaneous tissue [3, 4, 6]. Outside of the central nervous system, symptoms are minimal or absent. Subcutaneous cysticercosis presents as small, movable, painless nodules, which are more commonly noticed in the arms or chest [3, 7]. After a few months or even years, the nodules become swollen, tender and inflamed, and they gradually disappear [3]. Pulmonary and cardiac involvement of cysticercosis is extremely rare and is usually asymptomatic [1, 3, 5, 6]. Therefore, the correct diagnosis is made by biopsy or at autopsy, or indirectly by noting resolution of lesions following anticysticercal therapy with praziquantel or albendazole [5]. In the present case, the patient presented with dyspnoea, history of seizures and multiple subcutaneous nodules at the physical examination. In addition, there was rapid improvement of the lesions after the beginning of the specific therapy.
The CT scan findings of the cysticercosis lesions are very similar in all the affected organs. In most of the cases, there are cystic appearing lesions, which are hypointense with well defined edges, and commonly present a hyperdense central nodule, which represents the parasite head, called the scolex [3, 5]. Although not pathognomonic, the identification of the scolex in a cystic appearing lesion very much suggests the diagnosis of cysticercosis [9].
Pulmonary involvement has been described in very few reports. The CT scan usually demonstrates multiple random nodules of varying sizes [4, 5]. The tomographic appearance of nodular cysticercosis in the lung cannot be differentiated from other parasitic infections, such as echinococcosis, paragonimiasis and histoplasmosis, or conditions such as metastasis [4]. However, if association of chest wall and cardiac muscles lesions is seen, cysticercosis should be the first diagnosis considered. Our patient showed multiple random nodules with similar sizes on the lung CT scans. In addition, the association of cardiac and chest wall nodules was essential to suggest the diagnosis of cysticercosis.
In conclusion, cysticercosis should be considered in the differential diagnosis of multiple pulmonary nodules, mainly in those patients from endemic regions, who present similar lesions in the cardiac and chest wall musculature.
Received for publication December 16, 2005.
Revision received February 27, 2006.
Accepted for publication March 20, 2006.
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Abstract
Introduction
