Undiscovered Islands - So Close, Yet So Far (PDF)

A 30-year old female, visiting Canada from India, presented to ophthalmology with a 2-day history of right periorbital swelling, painful proptosis, fevers and chills. Initial examination suggested a clinical diagnosis of post-septal cellulitis with mild motility restriction, without optic nerve compromise, and patient was admitted and started on IV broad-spectrum antibiotics. Serologic analysis revealed mildly elevated CRP and white blood cell count. CT orbits revealed two ovoid-shaped ring-enhancing lesions in the right lateral and superior rectus muscles (Fig.1) and clear sinuses, atypical for infectious post-septal cellulitis, raising other considerations of the differential diagnosis. ACE, ANA, ANCA, HIV, and TB testing were negative. The patient received a course of oral steroids. As an inpatient, she was noted to have bradycardic episodes. Holter-monitor was unremarkable. Antibiotic and steroid treatment resulted in clinical improvement. MRI orbits was performed for further characterization, confirming the presence of the lesions in the right lateral and superior rectus muscles and an additional lesion in the left superior rectus muscle (Fig. 2). The largest ring-enhancing lesion in the right lateral rectus muscle did not show restricted diffusion, arguing against an abscess. Orbital biopsy was discussed, but deferred due to non-compliance. Given the bilaterality of these findings, a parasitic process, i.e. orbital cysticercosis was suspected, despite low eosinophil count and negative taenia solium serology. A course of albendazole, along with steroids was initiated, which led to the resolution of her symptoms. 8 weeks after her initial presentation, she presented to the ER with a 3-day history of nausea, vomiting, diarrhea, fevers and weakness. Abdominal sonography and CT ordered for iron deficiency and elevated liver enzymes showed a 3cm mass, likely arising from the neck of the pancreas, along with numerous lesions in kidneys, liver, T12 vertebral body, and periaortic/retroperitoneal lymphadenopathy (Fig. 3). A diagnostic test was performed.