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Letter
Isolated superior division oculomotor palsy in neurocysticercosis: a rare presentation
  1. Monisha K Brijlal Meena,
  2. Anila Khuteta,
  3. Raj Vashishtha
  1. Department of Ophthalmology, SMS Hospital, Jaipur, India
  1. Correspondence to Dr Monisha K Brijlal Meena, SMS Hospital, A-3, Mother Teresa Nagar, Jaipur 302004, India; drmonisha{at}yahoo.com

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Cysticercosis is the most common parasitic disease involving the CNS. It is caused by infestation of the larval form of Taenia solium, with humans being the primary host. Neurocysticercosis commonly presents with seizures, raised intracranial tension and dementia. The unusual location of the cysts may result in uncommon manifestations mimicking a host of neurological disorders.

Case report

A 15-year-old boy presented with a complaint of drooping of his right eyelid for 3 days that was sudden in onset. No history of trauma or any other significant history could be elicited. On examination, there was right-sided severe ptosis (7 mm) with very poor levator action (3 mm). There was limitation of movements only in dextroelevation on the right side (figure 1A), and ocular movements were not associated with pain. The patient complained of mild headache. The pupil was round, regular and reactive. His vision was 20/40.

Figure 1

(A) Picture of the patient showing limited movements only in dextroelevation along with severe ptosis on the right side. (B) Picture of the patient after treatment.

The results of the laboratory examination were normal. The left-side examination was normal. An initial contrast-enhanced CT scan was performed and revealed a conglomerated lobulated ring-enhancing lesion in the brainstem on the right side with mild perifocal oedema and eccentric calcified speck (figure 2A).

Figure 2

(A) Contrast-enhanced CT scan revealing a conglomerated lobulated ring enhancing lesion in the brainstem on the right side with mild perifocal oedema and eccentric calcified speck. (B) MRI showing small cystic lesions in the midbrain on the right side with eccentric speck within them.

Subsequently, an MRI was performed in which SET1and FSET2 axial images of brain with saggital T2W and coronal FLAIR images reported two small cystic lesions in midbrain on the right side with eccentric speck within them and moderate perilesional vasogenic oedema suggestive of inflammatory granuloma/NCC (figure 2B).

Based on the imaging results and the high prevalence of disease in our region, these findings were thought to represent neurocysticercosis.

The patient's serum ELISA was positive for cysticercosis. He was referred to the Neurology Department and was treated conservatively and given systemic steroids, which resolved the symptoms completely within 7 days. No surgical intervention was carried out. There was no ptosis on re-examination (figure 1B), and the ocular movements were complete in all directions.

Comment

Rare clinical presentations in patients with neurocysticercosis previously described include dorsal midbrain syndrome, isolated bilateral ptosis, papillitis, cerebral haemorrhage, painful cervical radiculopathy, progressive swelling of the arm, paraplegia due to an intramedullary cyst, third ventricular cyst, dystonia and nominal aphasia masquerading as transient ischaemic attacks.

The isolated paresis of superior division of oculomotor nerve affecting the levator superioris and superior rectus muscles is a rare presentation of neurocysticercosis and has not been previously reported to the best of our knowledge.1–3

References

Footnotes

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; not externally peer reviewed.