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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 2  |  Page : 106-108

Cysticercosis presented with nodules diagnosed on fine-needle aspiration cytology


1 Department of Pathology, King George’s Medical University, Lucknow, Uttar Pradesh, India
2 Department of Pediatric Surgery, King George’s Medical University, Lucknow, Uttar Pradesh, India

Date of Submission04-May-2016
Date of Acceptance04-Jul-2016
Date of Web Publication25-Apr-2017

Correspondence Address:
Madhu Kumar
Department of Pathology, King George’s Medical University, Shahmina Road, Lucknow 226003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7942.205170

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  Abstract 

Cysticercosis is a parasitic disease caused by the larval form of the cestode worm Taenia solium. It is commonly manifested as subcutaneous, intramuscular, eye, or brain nodules. We report two cases in an 8-year-old male child who presented with a cheek nodule, and another in a 25-year-old man who presented with a flank swelling. Both cases were diagnosed by fine-needle aspiration cytology. The use of fine-needle aspiration cytology highlights the cytomorphological diagnosis of cysticercosis in subcutaneous and intramuscular nodules.

Keywords: cestode, cutaneous, cysticercosis, fine-needle aspiration cytology, intramuscular, nodules


How to cite this article:
Kumar M, Kureel S N. Cysticercosis presented with nodules diagnosed on fine-needle aspiration cytology. Parasitol United J 2016;9:106-8

How to cite this URL:
Kumar M, Kureel S N. Cysticercosis presented with nodules diagnosed on fine-needle aspiration cytology. Parasitol United J [serial online] 2016 [cited 2017 Jun 26];9:106-8. Available from: http://www.new.puj.eg.net/text.asp?2016/9/2/106/205170


  Introduction Top


Human cysticercosis is a systemic parasitic disease caused by the larval form of Taenia solium. Cysticercosis is a common disease in Pork-consuming countries. It is endemic in Mexico, Central and South America, parts of Africa, Asia, and India [1]. The diagnostic role of fine-needle aspiration cytology (FNAC) in cysticercosis was first emphasized by Neelaiah et al. [2]. Since then, the spectrum of cytological details of cysticercosis covering the entire pathological range, from viable cysts through necrotic and calcified lesions, has been described [3].

We report these cases because of the uncommon site and unusual presentation, and because FNAC proved to be a successful preoperative tool for the diagnosis of subcutaneous cysticercosis.

Case 1

An 8-year-old male child presented with a cheek nodule that was present for the past 2 months, not associated with pain or difficulty in chewing. The nodule measured 1.5×1 cm, was soft in consistency, and palpable in the intramuscular plane. Clinically, it was preliminarily diagnosed as a cystic lesion or sialadenitis. FNAC was advised.

Case 2

A 25-year-old man presented with a flank painless slow-growing nodule that was present for the past 3 months, measuring 2×2 cm in size, soft in consistency, and palpable in the subcutaneous plane. The preliminary clinical diagnosis was lipoma or soft tissue neoplasm. Patient was sent for the flank nodule FNAC.

FNAC was performed on both cases using a 22-G needle and a 20 ml syringe. A straw-colored clear fluid aspirate was smeared on glass slides; two smears, one dry and one wet, were fixed in 95% ethyl alcohol and stained with May−Grunwald Giemsa and hematoxylin and eosin. On microscopic examination, the smears showed parenchymatous fragments of a parasite consisting of loose fibrillary material interspersed with small dark blue nuclei as well as numerous calcospherules within the substance of the fibrillary material that showed a honeycomb appearance ([Figure 1]a, [Figure 1]b and [Figure 1]d). In some places, the mixed inflammatory infiltrates consisted of neutrophils, lymphocytes, histiocytes, and foreign body giant cells ([Figure 1]c). The cytomorphological diagnosis was cutaneous cysticercosis. A biopsy was performed and the nodule removed was subjected to pathological processing, sectioning, and staining by hematoxylin and eosin. Histopathology showed an entire cysticercus surrounded by a thick fibrous wall and inflammatory infiltrates ([Figure 2]a). The larva, with its outer cuticle layer, middle nuclear layer, and inner parenchymal layer with extensive folding of the parenchymatous fragments, and sucker of the scolex were apparent ([Figure 2]b and [Figure 2]c). Calcareous spherules were observed in the inner layer of fibrous tissues ([Figure 2]d).
Figure 1 (A) Fine-needle aspiration cytology smears show cysticercus wall fragments (May−Grunwald Giemsa stain, ×100). (B) Loose fibrillary stroma intermixed with numerous small dark blue-colored nuclei (May−Grunwald Giemsa stain, ×400). (C) Mixed inflammatory infiltrate along with calcareous spherules (May−Grunwald Giemsa Stain, ×100). (D) Multiple blue calcareous spherules within the substance of the fibrillary material yielded a honeycomb appearance (May−Grunwald Giemsa Stain, ×400).

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Figure 2 (A) Larval cyst surrounded by thick fibrous stroma (hematoxylin and eosin stain, ×100). (B) A parenchymatous portion with extensive folding of the cysticercus cyst (hematoxylin and eosin stain, ×100). (C) Multiple calcareous spherules within the fibrous stroma (hematoxylin and eosin stain, ×400). (D) Cyst wall surrounded by a mixed inflammatory infiltrate with foreign body giant cells (arrow) (hematoxylin and eosin stain, ×400).

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  Discussion Top


Cysticercosis is a larval infestation by the cestode T. solium in both humans and pigs, acquired through ingestion of eggs excreted in feces by human carriers. Humans acquire this infection by drinking water or consuming vegetables such as cabbage, radish, and carrots contaminated with T. solium egg. Consuming undercooked pork that harbors the larva leads to taeniasis solium [4]. Humans are the only definitive hosts of T. solium harboring the adult tapeworm in their intestines (taeniasis), whereas both humans and pigs can also act as intermediate hosts and harbor the larvae in different internal organs (cysticercosis) including the brain [5],[6].

This is owing to autoinfection [7] because the eggs are infective on deposition. When humans ingest eggs, they become dead-end hosts of the larval stage of the parasite and develop cysticercosis similar to pigs. Autoinfection involves the retrograde transmission of proglottids from the intestines into the stomach, with the subsequent release of T. solium eggs into the human gut [8]. The eggs hatch in the upper intestine and the embryos migrate by lymphatics or blood to various organs of the body.

Clinically, cysticerci are difficult to differentiate from soft tissue lesions, lymphadenopathy, intramuscular nodules, subcutaneous cystic, or parasitic nodules. By FNAC, aspiration of clear fluid is a strong indicator of parasitic infection in a palpable subcutaneous or intramuscular nodule [9]. Aspirates of lesions may contain fragments of the bladder wall, including calcareous corpuscles and detached single hooklets in the fibrillary background. These hooklets are characterized by the presence of a refractile pointed end and a nonrefractile, bifurcated blunt end. The calcareous corpuscles are a unique feature of cestode tissue. These spherical, noncellular masses occur in the parenchyma and are especially prominent in larval cestodes. The corpuscles are seen as small, dense basophilic-purple round structures either singly or in clusters in hematoxylin and eosin stain [10]. The viable cyst and the necrotic and calcified lesions all have distinctive cytomorphological patterns. The viable cyst yields clear fluid and shows fragments of the bladder wall in a clear acellular background. Aspirates of necrotic lesions may contain fragments of the bladder wall, including calcareous corpuscles and detached single hooklets.

Another unusual cause for subcutaneous swelling is the hydatid cyst and cytomorphological details help to distinguish it from Cysticercus cellulosae. The bladder wall is thin and membranous in cysticercus, whereas it is thicker, acellular, and lamellated in a hydatid cyst [11]. Cysticercus has only one scolex that is large, almost 1 mm in diameter, with two rings of alternating large and small hooklets measuring 170 and 130 μm, respectively. The scolex is visible to the unaided eye and, along with the hooklets, can be easily recognized at scanning magnification. In contrast, hydatid cysts have multiple daughter cysts within a parent cyst, and hence may yield many scolices in a clear aspirate. In the larval cyst of Echinococcus spp., individual scolices are small and the hooklets measure 22 and 40 μm, and can be identified only at higher magnification [9],[11]. FNAC is a well-recognized diagnostic procedure for the evaluation of subcutaneous cysticercosis [12].Both patients received antihelminthic treatment and responded well after treatment.

Conclusion

Cysticercosis was diagnosed by FNAC in our two patients and confirmed by surgical removal. Cytological diagnosis is quite straightforward in cases where the typical parasite structure is identified in the cytopathology smears and/or sections. However, in other cases, where the presence of chronic inflammatory infiltrate and fibrillary dirty background is identified, always be think for the possibility of cysticercosis. Typical parasite structure is identified in the cytopathology smears.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kraft R. Cysticercosis: an emerging parasitic disease. Am Fam Physician 2007;76:91–96.  Back to cited text no. 1
    
2.
Neelaiah S, Neha S, Qutubuddin C, Kalaivani A. Fine needle aspiration cytology of cysticercosis. Acta Cytol 2010;54:103–105.  Back to cited text no. 2
    
3.
Singh N, Arora VK, Bhatia A. Are all subcutaneous parasitic cysts cysticercosis? Acta Cytol 2006;50:114–115.  Back to cited text no. 3
    
4.
Gill M, Dua S, Gill P, Gupta V, Gupta S, Sen R. Cytomorphological spectrum of subcutaneous and intramuscular cysticercosis: a study of 22 cases. J Cytol 2010;27:123–126.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Prasad KN, Prasad A, Verma A, Singh AK. Human cysticercosis and Indian scenario: a review. J Biosci 2008;33:571–582.  Back to cited text no. 5
    
6.
Agarwal A, Murty OP, Jain M. Fine needle aspiration cytology in the diagnosis of cysticercosis cases. Asian Pac J Trop Med 2009;2:49–53.  Back to cited text no. 6
    
7.
Lakhey M, Hirachand S, Akhter J, Thapa B. Cysticerci in palpable nodules diagnosed on fine needle aspiration cytology. J Nepal Med Assoc 2009;48:314–317.  Back to cited text no. 7
    
8.
Adhikari RC, Aryal G, Jha A, Pant AD, Sayami G. Diagnosis of subcutaneous cysticercosis in fine needle aspirates: a study of 10 cases. Nepal Med Coll J 2007;9:234–238.  Back to cited text no. 8
    
9.
Handa U, Garg S, Mohan H. Fine needle aspiration in the diagnosis of subcutaneous cysticercosis. Diagn Cytopathol 2008;36:183–187.  Back to cited text no. 9
    
10.
Rao RN, Krishnani N, Malhotra K, Suresh B, Mehrotra R. Dilemmas in cytodiagnosis of subcutaneous swellings: mimics and look-alikes of cysticercosis. J Clin Pathol 2010;63:926–929.  Back to cited text no. 10
    
11.
Singh N, Arora VK, Bhatia A. Are all subcutaneous parasitic cysts cysticercosis? Acta Cytol 2006;50:114–115.  Back to cited text no. 11
    
12.
Batrani M, Kaushal M, Chaturvedi NK, Yadav R. Fine needle aspiration of subcutaneous cysticercosis. Diagn Cytopathol 2010;38:347–348.  Back to cited text no. 12
    


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