Cysticercosis Of The Breast

Journal of Diagnostic Medical Sonography OnlineFirst, published on September 22, 2009 as doi:10.1177/8756479309340228

JDMS  XX:XXX-XXX  Month/Month XXXX

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Cysticercosis of the Breast VAISHALI UPADHYAYA, MD DIVYA NARAIN, MS, MCh SABYASACHI SARKAR, MD

Cysticercosis, although common in developing nations, is an uncommon cause of a breast lump. This article reports a case from India, where a young woman presented with a firm, nontender breast lump. Breast sonography imaging with a high-frequency transducer revealed a well-defined cystic lesion with an internal echogenic nodule and surrounding hypoechoic area. Subsequently, fine-needle aspiration cytology was performed, which confirmed the diagnosis of cysticercosis. Key words: breast, lump, cysticercosis, parasitic infestation

From Sarkar Diagnostics, Mahanagar, Lucknow, India. Correspondence: Vaishali Upadhyaya, MD, Sarkar Diagnostics, C-1093, Sector A, Mahanagar, Lucknow, India. E-mail: vshali77@ yahoo.co.in. DOI:10.1177/8756479309340228

Cysticercosis occurs from infestation by Cysticercus cellulosae, the larval form of the pork tapeworm, Taenia solium. Humans are the definitive hosts of T. solium. There is intermittent fecal shedding of egg containing pro-glottids or free T. solium eggs, which are ingested by pigs (the intermediate host) in contaminated food or water. Embryos of T. solium penetrate the gastrointestinal mucosa of the pig with subsequent hematogenous spread to peripheral tissues with formation of larval cysts—cysticerci. When humans consume undercooked pork, an intestinal tapeworm will be formed, 1 and the life cycle of the worm is completed. Ingestion of T. solium eggs present in contaminated food or water or unwashed hands or by means of an autoinoculation resulting from reverse 2 peristalsis leads to cysticercosis in humans. Cysticerci can remain viable at this stage for as long as 10 years in humans. No inflammation is elicited by living larvae. When larval death occurs, there is a vigorous inflammatory response,

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which produces symptoms based on the anatomic 3 location. Cysticercosis is common in the developing world. Although it can occur in any tissue, involvement of the breast is uncommon. This report illustrates one such case from India, where a young woman presented with a breast lump.

Case Report A woman in her early 20s came to the sonography department for evaluation of the breasts. She complained of a lump in the right breast for the past 2 months associated with intermittent pain. She gave no history of fever or nipple discharge. Examination revealed a firm, nontender mobile lump in the right breast in the lower inner quadrant. A clinical differential diagnosis of fibroadenoma or fibrocystic disease of the breast was made. Breast sonography was performed using a high-frequency transducer of 11 to 14 MHz (Voluson 730 Expert, GE Kretz, Vienna, Austria). Imaging demonstrated a well-defined cystic lesion measuring 14 × 12 mm in lower inner quadrant of the right breast at the 4 o’clock position in zone I with the position of the transducer being radial to the mass. The cystic lesion contained an echogenic nodule measuring 10 mm. There was a hypoechoic area of 32 × 20 mm surrounding the cystic lesion (Figures 1 and 2). Doppler imaging did not show any vascularity in the cyst wall or the echogenic nodule. A provisional diagnosis of cysticercosis with surrounding inflammatory phlegmon was made. Subsequently, fine-needle aspiration cytology (FNAC) was carried out, which confirmed the diagnosis.

Discussion Cysticercosis affects about 50 million people worldwide. It is endemic in Mexico, Latin America, 1 sub-Saharan Africa, India, and East Asia. In humans, the infection is acquired by the ingestion of eggs of T. solium. This can occur from ingesting contaminated food or water, ano-oral contamination, or reverse peristalsis. Cysticerci may be found in almost any tissue. Clinically, involvement of the central nervous

FIGURE 1.  Sonographic image of right breast showing a cystic lesion with surrounding hypoechoic area between 3 to 4 o’clock positions.

FIGURE 2.  Sonographic image of right breast showing an echogenic nodule measuring 10 mm within the cystic lesion.

s­ ystem is considered the most important site of involvement, with patients often presenting with seizures and headache. Other common sites of involvement are the subcutaneous tissue, skeletal muscle, heart, and eye. The breast is an uncommon site of involvement. 4 Saigal et al. studied 156 cases of cysticercosis occurring over 27 years in the city of Patiala (Punjab, India). They found that the majority of cases (87.82%) were solitary lesions. The most frequent sites of involvement were the upper arm, chest wall, eye, abdominal wall, and neck, followed by tongue, face, and breast. These lesions were located in the subcutaneous tissue or the muscles. Only 5 of these cases were seen in the female breast. In another study by Amatya and 5 Kimula, who studied cysticercosis in Nepal, of

CYSTICERCOSIS OF THE BREAST / Upadhyaya et al.

the 62 cases that occurred over a 5-year period, only 8% were found in the breast. Patients with cysticercosis of the breast present with a nontender breast lump. High-frequency sonography can accurately diagnose the condition. The salient diagnostic feature of a cysticercus granuloma is the presence of an oval or rounded well-defined cystic lesion with an eccentric echo6 genic nidus within. This feature has been reported in sonography of cysticerci in the breast, skeletal 3,7–9 The muscle, subcutaneous tissue, and eye. average size of cysticerci reported has been 19 mm 5 in diameter. In the muscular form, four different sonographic appearances are described. The first type is a cyst containing an echogenic structure inside (scolex) with an inflammatory mass around it. This is seen with larval death when there is leakage of fluid from the cyst, and it leads to local pain and myalgia. The second appearance is an irregular cyst with minimal fluid on one side, indicating leakage of fluid. It occurs as a result of cyst degeneration and elicits a chronic inflammatory response with collection of fluid around the cyst. This is the mass-like pseudotumor or abscess-like type. The third appearance is a large, irregular collection of exudative fluid within the muscle, and the cyst containing the scolex is situated eccentrically within the collection. This also occurs because of chronic intermittent leakage of fluid from the cyst and is the pseudohypertrophic type. The fourth appearance is that of calcified cysticercosis. Calcified cysticerci produce multiple millet seed– 10 shaped elliptical calcifications. The sonographic differential diagnosis of intracystic masses in breast includes papilloma and malignant lesions such as infiltrating ductal carcinoma and papillary carcinoma. Clinical evaluation and imaging can be combined to rule out these conditions. These can be associated with bloody nipple discharge and can present as irregular, hard, fixed masses in breast. Irregular or ill-defined margins, heterogeneous echotexture, and vascularity of the solid component are noted in sonography of these lesions. This case showed a well-defined cystic lesion with an internal echogenic nodule and surrounding inflammatory phlegmon. Neither the cyst

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wall nor the nidus showed any vascularity. These features, along with the clinical evaluation, enabled us to differentiate it from other intracystic masses. FNAC is useful in diagnosing parasitic infections. Hooklets and fragments of wall along with inflammation are required for the definitive diagnosis of C. cellulosae. Whenever clear fluid with eosinophilic prominence is aspirated, a search for 11 12 hooklets should be made. Agrawal et al. performed FNAC in a case of swelling in the left submandibular region. Clear fluid was obtained. Subsequently, smears were stained with Diff-Quik and haematoxylin and eosin. Classis scolices, hooklets, and lymphocytic and eosinophilic infiltrate were found, which established the diagnosis of cysticercosis. If FNAC is inconclusive, excision biopsy of the swelling is carried out, along with a histopathological examination. Microscopic findings have been 13 well described by Agnihotri et al. in a case of cysticercosis of the breast. They showed that the wall of the cysticercus was lined by three layers. These included a corrugated cuticular layer with hair-like protrusions in contact with host tissue, a thin middle layer, and a thick inner layer containing a loosely packed network of small canaliculi with infiltration of lymphocytes, plasma cells, and eosinophils. Multinucleate giant cells and foreign body granulomas were seen in the wall of the cyst. 14 Kapila and Verma reviewed 8364 breast aspirates over a period of 15 years for parasitic infections. They detected eight cases of cysticercosis. Of these, seven were diagnosed by FNAC and one by excisional biopsy based on identification of parts of the parasite.

Summary Cysticercosis is a parasitic infestation that is commonly seen in developing nations. It is an uncommon cause of a breast lump. When breast tissue is involved, the patient presents with a firm, nontender breast lump. A clinical diagnosis is not possible; hence, high-resolution sonography plays an important role in establishing the diagnosis. The cysticercus granuloma is seen as a well-defined cystic lesion with an internal echogenic nidus (scolex). This is a

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characteristic appearance that excludes other causes of breast lumps. Diagnosis subsequently can be confirmed by FNAC or histopatholgical examination. This case emphasizes the fact that cysticercosis should be considered in the differential diagnosis of a breast lump in endemic areas and in immigrant populations in nonendemic areas.

References   1. Tenzer R, Blumstein HA: Cysticercosis. http://www .emedicine.com/emerg/TOPIC 119.HTM   2. Arora PN, Sanchetee PC, Ramakrishnan KR, Venkataram S: Cutaneous, mucocutaneous and neurocutaneous cysticercosis. Indian J Dermatol Venereol Leprol 1990;56:115–118.   3. Mittal A, Das D, Iyer N, Nagaraj J, Gupta M: Masseter cysticercosis: a rare case diagnosed on ultrasound. Dentomaxillofac Radiol 2008;37:113–116.   4. Saigal RK, Sandhu SK, Sidhu PK, Gupta KK: Cysticercosis in Patiala (Punjab). J Postgrad Med 1984;30:46.   5. Amatya B, Kimula Y: Cysticercosis in Nepal: a histopathologic study of sixty-two cases. Am J Surg Pathol 1999;23:1276.

  6. Mittal A, Gupta S, Mehta V, Gupta R: Anterior abdominal wall cysticercosis: the role of high–resolution USG. Indian J Radiol Imaging 2008;18:266–267.   7. Oh KK, Jeon TJ, Jeong WH: Cysticercosis of breast: a case report. J Korean Radiol Soc 1995;32:835–840.   8. Smiti S, Sripathi H, Naik L: Unusual location of cysticercus lesions in soft tissue: report of three cases. Indian J Radiol Imaging 2003;13:157–158.   9. Pushker N, Bajaj MS, Chandra M, Neena: Ocular and orbital cysticercosis. Acta Opthal Scand 2001;79: 408–413. 10. Vijayaraghavan SB: Sonographic appearances in cysticercosis. J Ultrasound Med 2004;23:423–427. 11. Patnayak R, Kalyani D, Rao IS, Prayaga A, Sundaram C, Jena A: Cysticercosis: the hidden parasite with short review of literature. Internet J Infect Dis 2007;6(1). 12. Agrawal KC, Mishra DP, Das PK: Cysticercosis diagnosed by fine needle aspiration cytology. Acta Cytol 2004;48:471. 13. Agnihotri S, Talwar OP, Pudasaini S, Baral R: Cysticercosis of breast: a case report. Pol J Pathol 2006;57:53–54. 14. Kapila K, Verma K: Diagnosis of parasites in fine needle breast aspirates. Acta Cytol 1996;40:653–656.