Epstein, E

Heinz, HJ

Proctor, NSF

English

AJOL - African Journals Online

602 S.A. MEDICAL JOURNAL 18 July 1959betref, kan ons nie nalaat om die werk van organisasiessoos die Suid-Afrikaanse Nasionale Raad vir Alkoholismemet sy verskillende plaaslike vertakkinge, en die Alko-holiste Anoniem te noem nie. Hierdie liggame tree veral opop die gebied van die beplanning en organisasie en dielewer van vrywillige diensre vir die behandeling en rehabili-tasie van Alkoholiste. Sonder die uitstekende werk wathierdie liggarne doen sou ons skaars kon klaarkom.Tot tyd en wyl ons oor meer gegewens beskik aangaandedie aard van die toestand van alkoholisme, en tot tyd enwyl ons oor beter terapeutiese geriewe en middels beskik,kan ons nie beter doen nie as om, soos een van die streek-afdelings van die Suid-Afrikaanse Nasionale Raad virAlkoholisme, te mik daama om die werk te koordineer vanmediese, maatskaplike, kerklike, en lekewerkers* en diestryd teen alkoholisme, soos teen elke ander openbaregesondheids-vraagstuk, aan te knoop deur opvoeding, navor-sing en dienste.• Kyk ook na die aankondiging op bladsy 611 in h.ierdie uitgawe oor dieKongres oor Alkolisme wat vroeg aanstaande jaar gehou sal word.INTRA-OCULAR COENURUS INFESTATIONE. EpSIEIN, Ophthalmological Department, Boksburg-Benoni Hospital, and N. S. F. PRocrOR and H. J. lIEINz,Departments of Neuropathology and Parasitology, South African Institute for Medical Research, and Department ofPathology. University o/the Witwatersrand, JohannesburgCoenurus is the term applied to the cystic larval stage of atapeworm in which' there are numerous scolices in contrastwith cysticercus, and no evidence of daughter cysts as inhydatid. This particular larval form, as well as thecharacteristic shape of the rostellum and hooklets and certainfeatures of the vagina in the adult worm, are considereddiagnostic systematic traits of the subgenus Multiceps.The proper host of the adult worm of a number of speciesof Multiceps is not known, but it is safe to say that variouscarnivores, especially canines, harbour it. Intermediatehosts may vary greatly. The greatest number are to be foundamong the rodents, but various primates have been incrimi-nated who, it may well be, are incidental intermediate hosts,having been infested along the same lines as man, in whomsporadic cases have been reported.Multiceps coenurus (coenurus cerebralis) has a wide hostdistribution. It varies morphologically according to theintermediate host and the tissue in which it is found. Thoughit is most frequently reported as inhabiting the centralnervous system, coenurus occurs in animals in the inter-muscular connective tissue, the abdominal cavity, the thoracicsheath, and the pericardial sheath. Many human coenurusinfestations are doubtlessly passed off as hydatid cysts.The following case, which illustrates the value of a surgicalexploration of the uveal tract, is only the third case on recordof an intra-ocular coenurus infestation.The first case was reported by Boast:' and by Raper andDockeray2 in an adult Native male in Uganda. Clinically, a largewhitish cyst was noted projecting from the nasal side of the fundus,apparently filling the vitreous and in contact with the posteriorsurface of the lens. Movements were detectable in the cyst,suggesting two scolices. The eyes was very painful and the patientrequested enucleation. He had presented himself at the clinic 10months earlier with signs and symptoms of iritis. Atropine dropswere instilled into the eye and he was asked to wait for furtherexamination, but unfortunately did not do so. Examination of theenucleated eye revealed a trilocular cyst with numerous scolice-sand was considered to be multiceps coenurus.The second case was reported by Wainwright,3 of Durban, inan enucleated eye. A Bantu male aged 51 cOIilplained of a painfuleye; the condition was diagnosed as conjuctivitis and iritis. Un-fortunately no ophthaImoscopic report is available. Four monthslater there was a marked increase in tension, great pain, proptosis,ciliary staphyloma, and dense keratic precipitates. The eye wasenucleated with a tentative diagnosis of neoplasm. Examinationrevealed a bilocular cyst filling the vitreous, which was identifiedas coenurus cerebralis.PRESENT CASEThe present case concerned a female European child aged 3tyears. She was born in the Transvaal bljt for the year beforeconsultation had been resident in SwaziIand. The mother hadnoticed that during the previous 2-3 months the left eye had beenvariably congested and that at times the child complained that itwas sore. The mother thought that the child had bumped theeye when the symptoms first appeared; she imagined that shesaw a bruise just lateral to the eye. The patient's doctors hadtreated her for conjunctivitis.Examination showed a mildly flushed eye, a small clottedstreak of blood on the iris, and a few delicate posterior synechiae.The vitreous was very hazy and fundal details could not be seen,but it was obvious that a white raised mass was present on thenasal side. The tension of the eye was normal.Good and complete mydriasis was obtained with homatropineand cocaine drops plus one drop of I % adrenalin. It was thenobvious that an extensive smooth high elevation of the nasalfundus was present, reaching from the ciliary body to apparentlythe region of the disc, although it was extremely difficult to definethe disc on account of the vitreous haze. The maximal elevationwas just below the horizontal meridian between the ora serrataand the equator. The swelling tapered off below and above, sothat the retina appeared flat in the oblique meridians althoughit had the same oedematous whitish appearance as on the swellingitself. No movement was noticed in the mass, which was speciallyexamined for this phenomenon. The temporal half of the retinaappeared normal, but the anterior region only could be examinedthrough the cloudy vitreous.As far as could be ascertained in a child of this age there wasno perception of light \vith this eye. Transillumination undergeneral anaesthesia showed the mass to be translucent.The findings suggested a granulomatous uveal inflammatorylesion and, amongst the possible ·causes, tuberculosis, Coats'sdisease, cysticercosis, hydatid disease and even hookworminfestation were considered. Neoplastic disease was excluded asunlikely on the physical findings. This is discussed further below.InvesiigationsHaemoglobin 14· 5 g %. Leucocytes 9,600 per c. mm. (neutrophils52 %, Iymphocytes 40 %, monocytes 4 %, eosinophils 3 %, baso-phils 1 %). Sedimentation rate, 17 mm.jhour. Ide test negative.Stool examination for parasites, negative. Hydatid complement-fixation test, positive (result received after operation).X-ray examination of head, chest and legs showed noabnormality.OperationSurgical exploration of the mass was considered at least forbiopsy to pave the way if possible for rational therapy. Undergeneral anaesthesia a large scleral flap was reflected. The twoparallel incisions starting a few mm. from the limbus were 2-3mm. above and 4-5 mm. below the borders of the medial r:..ectus·muscle. A vertical incision joining these two horizontal cuts wasplaced a few mm. behind the insertion of the medial rectus, which18 J ulie 1959 S.A. TYDSKRIF VIR GENEESKUNDE 603muscle had first been detached. The larger posterior flap extendedto just behind the equator, the furthest point that could be reachedwithout undue traction on the globe. Greater derails of a similarapproach for removal of a cysticercus have been published else-where.' The eye had been softened as much as possible by pre-operative 'diamox' retrobulbar anaesthesia, and finally aparacentesis of the anterior chamber just before the scleral incisionswere carried through to the choroid. The exposed choroid waspaler than normal. The region corresponding with the maximalswelling in the fundus was gently incised, and suddenly a smallwhite cystic mass herniated through the incision. A single scolexwas visible in the small bladder and the whole simulated a typicalcysticercus cellulosae. With this assumption in mind a pair ofiris forceps were applied with closed blades to sweep the cyst fromthe wound in the choroid. The gentle pressure applied made thecyst bulge, and more scolices became evident. The choroidalwound was then enlarged and the endocyst of what was thenthought to be a hydatid oozed out with a little pressure. Part ofthe outer ectocyst wall was excised for investigation and theremaining now collapsed cavity was gently swabbed with lO %formalin. The cavity extended from about the middle of the ciliarybody to midway between equator and disc.The adjacent tissue was then .:xarnined, both externally and bymeans of the headlamp ophthalmoscope worn throughout theoperation,5 to exclude the chance of a second cyst. Six 0 mildchromic catgut was used for closure ofall incisions and reattachmentof the medial rectus muscle. Diathermy was available to coagulateany raw surface should a biopsy only have been taken, e.g. in thecase of a mberculoma. A long-acting antibiotic preparation wasgiven once postoperatively and oral steroid therapy was alsocommenced. Convalescence was uneventful.The vitreous cleared and the oedema of the nasal retina settled,but its appearance was abnormal, suggesting a gliosis and fibrosiswith patchy pigmentation. The temporal region appeared normal.The optic disc was very distorted, especially its nasal side. Fourmonths after the operation the disc was still red, but there wasapparently no return of vision, although the pupil reacted a littleto light. Cosmetically, however, the eye appeared normal. Un-fortunately follow-up was limited to 6 months, when contact waslost.Pathological FindingsThe cyst was about 8 mm. in diameter but of rather irregularshape (Fig. 1). Numerous white nodules of about 1-2 mm. indiameter were clearly visible in the wall of the cyst; freshpreparations showed these to be definite scolices (Fig. 2). Theindividual scolices consisted of a rostellum with a double row ofhooklets and 4 suckers typical of the taenia type of tapeworm(Fig. 3). There were no daughter cysts. The hooklets of the armedrostellum could not be measured in the original condition, so thatit was necessary to tease one of the scolices apart. There were 2rows of hooklets present. Measurements of both large and smallhooks showed that they clearly fell within the small variationlimit .of Multiceps multiceps-large hooks 150-170 J.L and smallhooks 90-130 J.L as given by Baer.6 Hooks are known to be reliablemorphological features because numbers, sizes and shapes arerather con.stant for each species.DISCUSSIONHuman infestation by cysticercus cellulosae, coenuruscerebralis and hydatid is known to occur in South Africa.The brain, meninges and cerebrospinal-fluid pathways arenot infrequently involved, with serious results. 3 ,7-12This is the second case of multiceps coenurus in the eyedescribed in South Africa. It is probable that this childwas infected from the ingestion of eggs passed in the stoolsof an infected dog. However, attempts to trace infectionto the child's pet dog have proved fruitless, so that the sourceof the infection remains unknown.Coenurus cysts appear to develop in man in certain welldefined situations only; these include the cerebrospinal-fluidpathway and, as indicated by this case, the uvea of the eye.Degenerated cysts are sometimes encountered in the centralFig. I. Macroscopic appearance of the opened fresh cyst. X 12.Fig. 2. Scolices evaginated from the wall of the cyst, x 38.604 S.A. MEDICAL JOURNAL 18 July 1959Fig. 3. The rostellum of one of the scolices~ showing 3 of the 4 suckers andthe double row of hooklets, X 150.nervous system which are obviously derived from tapeworms,but their true identity cannot be determined because of theabsence of scolices. Similar cysts, containing numerousscolices, have been described in the Belgian Congo, whereFain has succeeded in identifying them as the larval stageof the tapeworm Multiceps (Taenia) braunii.'3Intra-ocular helminthic infestations occur rarely. Cestodes,nematodes and diptera are recorded. Hydatid cysts withinthe eye are very rare. Cysticerci are more frequent. Whenthe parasite has ruptured into the vitreous, the diagnosis isfairly simple. However, when the cyst is subretinal andespecially when it is within the uvea, the diagnosis becomesmore difficult. The problem of malignant neoplasm thenarises.In the adult a melanoma might present the greatestdifficulty. Parasitic cysts usually produce signs of in-flammation, but so may the melanomas, especially whenundergoing necrosis. 14 Melanomas, however, usually occuras large tumours, which makes the diagnosis almost self-evident, whereas a small cyst with inflammatory changes ismore likely a parasite. The features of pigmentation andtransillumination help, but cystic change in the necroticcentre of a melanoma might make differentiation almostimpossible.In the young child a malignant melanoma is exceptiona1'5and one completely translucent with inflammatory changesprobably hypothetical. The more likely problem wouldbe the exophytum type of retinoblastoma. This wouldpresent with a smooth elevated retinal surface, but clinicalinflammatory changes have not been described with this typeof tumour. a Wilder'· described 46 enucleated eyes fromyoung children where a clinical diagnosis of retinoblastomahad been made and in which histologically no tumours werefound. The pathological diagnosis of pseudo-tumour orCoats's disease was made. Re-examination of these 46 eyesby serial sections then showed the definite presenceof nematode larvae in 24 and bodies suggestive of degeneratinglarvae in the remaining 22. Although it was impossible todetermine the exact genus of the larvae they were consideredto be hookworm.Probably the earliest features in the case described in thispaper, and in the 2 previously described cases in atives,were a localized swelling in the fundus, vitreous haze, and aniritis. It is suggested that cases with such features-selectedafter due consideration of laboratory investigations, increas-ing swelling and inflammatory reaction, etc.-should be sub-mitted to what might be called exploratory sclerotomy. Hadthis case been seen sooner there is every chance that usefulvision would have been saved.SUMMARYA case of intra-ocular infestation with a coenurus of Multicepsmulticeps, and its successful removal, is described. Aspectsof intra-ocular helminthic infestation and the relation to thediagnosis of pseudo-tumour are discussed. The value ofexploratory sclerotomy is suggested.We are indebted to the Superintendent of the Boksburg-BenoniHospital and the Director of the South African Institute forMedical Research for permission to publish the case.Mr. M. Ulrich of the Photographic Department of the SouthAfrican Institute for Medical Research was responsible for thephotographs.REFERENCESI. Boase, A. J. (1956): Brit. J. Ophtha!., 40, 183.2. Raper, A. B. and Dockeray, G. C. (1956): Ann. Trap. Med.-Parasit., 50, 121.3. Wainwright, J. (1957): J. Path. Bact., 73, 347.4. Epstein, E. (1948): S. Afr. Med. J., 22, 625.5. Idem (1950): Arch. Ophtha!. (Chicago), 43, 373.6. Baer, J. G. (1927): 11th and 12th Rep. Director Vet. Educ. Res., Onderste-poort, parr I, p. 63.7. Becker, B. J. P. and Jacobsen, S. (1951): Lancet, 2, 198.8. Idem (1951): Ibid., 2, 1202.9. Proctor, N. s. F. (1955): Proc. 2nd lot. Coogr. Neuropath., London, p. 199.10. Kuper, S., Mendelow, H. and Proctor, N. S. F. (1958): Brain, 81,235.11. Watson, K. C. and Lourie, W. (1955): Lancet, 2, 1321.12. Idem (1956): S. Afr. Med. J., 30. 964.13. Fain, A. (1956): Nature (land.), 178, 1353.14. Reese, A. B. (1951): Tumors of rhe Eye, pp. 244 and 91. London: CasseIl.15. Fuchs, E. Quoted by Duke-Elder, W. S. (1940): Turbook oj Ophthalmology,vol. 3. p. 2478. london: Kimpton.10. Wilder, H. C. (1951): Trans. Amer. Acad. Ophtha!. Otolaryng., 55, 99.DIE SUID-AFRIKAANSE AKADEMIE VIR WETENSKAP EN KUNSDie Suid-Afrikaanse Akademie vir Wetenskap en Kuns vier sy50-jarige bestaan te Stellenbosch, Kaap, vanaf 24 lOt 29 Julie1959. Die Tak Simon van der Stel van die Afdeling Geneeskundevan die Akademie reel in hierdie verband 'n vergaoering te Stellen-bosch op Donderdagaand 23 JuJie om 8 rim. in die Anatomie-lesingsaal in die D. F. MaJan-gebou. As sprekers sal optree prof.H. W. Snyman (,Geneeskundige onderrig in Afrika') en prof.M. W. Woerdeman (onderwerp van eie keuse). Professor Snymanis Hoof van die Depanement Interne Geneeskunde van die Uni-versiteit van Pretoria en professor Woerdeman is die bekendehistoloog-anatoom van die Gemeentelike Universiteit van Amster-dam en is ook voorsitter van die Koninklike Nederlandse Akade-mie. Lede van die Mediese Vereniging van Suid-Afrika is baiewelkom by hierdie vergadering.

Intra-ocular coenurus infestation

https://www.ajol.info/index.php/samj/article/download/173214/162619

Intra-ocular coenurus infestation

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online