Intramuscular cysticercosis: an unusual presentation: report of three cases

Abstract

The term endemic is a fading entity as many diseases are getting globalized. Cysticercosis was considered a third-world disease but that is fast changing as sporadic case reports have been reported in Western literature. Though presence of cysticercal soft tissue involvement is a pointer for evaluation of central nervous system, we present three different cases of intramuscular cysticercosis in varied locations, without central nervous system involvement, which responded to conservative treatment. We discuss in this report the unusual clinical presentation, the diagnostic difficulties, the image findings, and management of these lesions.A 19-year-old boy presented to us with claw deformity in the right hand in the form of flexion contracture of the fingers. He gave a history of dull pain in the right forearm in the proximal volar aspect. There was no history of any injury.He had difficulty in grasping the objects and writing with right hand, which was his dominant hand. On clinical examination, there was a diffuse swelling in the volar aspect of the proximal one-third of the right forearm. There were no signs of acute inflammation. There was tenderness on deep palpation. The neurological examination of the ulnar, radial, and median nerve both for sensory disturbances and motor supply was normal.The X-ray of the part was normal. The blood examination revealed normal total and differential leukocyte count, and the erythrocyte sedimentation rate (ESR) was 26 mm/h. The serum calcium, phosphorous, and alkaline phosphatase levels were normal. The magnetic resonance imaging (MRI) scan of the forearm revealed marked muscular edema involving the ulnar aspect of the flexor digitorum profundus (FDS). An ovoid lesion with peripheral hypointensity and central hyperintensity on T2 W images was seen involving the medial aspect of the muscle. The lesion was intramuscular and thick-walled measuring 3 cm in length and 2 cm in diameter. Lesion showed central hyperintensity on T1 W images with the adjacent muscle showing mild hyperintensity on T1 W images. The edema involving the FDS extended till the middle of the forearm. The muscle appeared bulky and expanded by the lesion. The adjacent muscles were spared and there was no bony involvement (Fig. 1).The post-contrast study showed marked enhancement of the intramuscular lesion. The lesion was ovoid along the long axis of the muscle with thin rim of enhancement around the lesion in the muscle. The intermuscular septal enhancement around the lesion extended into the plane of the vascular pedicle. There was a small enhancing cyst-like structure in the center of the lesion with a size of 6 mm in diameter. The adjacent muscles were normal and without enhancement (Fig. 2).