ORAL PATHOLOGY

Parasitic cysts:Hydatid cyst ,cysticercus

cellulosae , Trichinosis
:Prepared by group 8 :Supervised by
‫أحمد السرحي‬- Dr.Tasneem Hamdan
‫محمد أبوالفول‬-
‫آية المقادمة‬-
‫منار البزم‬-
‫دانا الحاج‬-
‫إيناس صالح رجب‬-
‫إيناس منذر رجب‬-
 INTRODUCTION
 Parasitic cysts occur in the mouth although they are
rare.
 Most of the reported cases of parasitic cysts in the
mouth have been caused by the class Cestoidea
(flatworms and tapeworms) These include the genera
Echinococcus and Taenia .
 The class Nematoda (roundworms) produce oral
lesions only exceptionally rarely.
 DEFINITION DISEASE
HYDATID CYST

 Hydatid cyst is a pseudocyst of head and neck region

occur in hydatid disease or echinococcosis, which is one of
the most geographically prevalent zoonosis.

 This zoonotic infection in humans is mainly caused by

infection by the larval stage of the dog tapeworm
Echinococcus granulosus .
 The tapeworm infestation is widespread in sheep, goats,
cattle, and dogs.
 This chronic disease is present worldwide among herding
populations who live in close proximity to dogs and herd
animals.
• The great majority of cysts are found in the liver,
but others are found in the lungs, bones and brain.

 Hydatid disease is common in sheep-raising

countries such as Australia, NewZealand,
Argentina and South Africa, but only about 2%
of cases affect the oral and maxillofacial regions.

 Between20% and 30% of patients will have

multiorgan involve-ment, which always affects the
liver as well as other sites.
ETIOLOGY AND PATHOGENESIS
 It is acquired by the ingestion of eggs or gravid
proglottids excreted from the definitive host or
from eggs contained in faeces or plants contaminated
with eggs or soil followed by direct hand to mouth
transfer.
 The larvae released from the eggs penetrate

the gut wall, enter the bloodstream, and disseminate

to the deeper organs.
 The mainstream of the cysts is found in the liver,

but others are found in lungs, bones, and brain and

maxillofacial region.
Life cycle of hydatid cyst

http://www.ijdentistry.com/arti
cle.asp?issn=0975
962X;year=2015;volume=6;issue
=3;spage=157;epage=160;aulast=
Lavanya
 :CLINICAL FEATURE
Age: the prevalence is highest in second to fourth decades .
of life.
Sex: male as female (1 : 1)

Site:
 The most common sites were the salivary glands and the pterygo-
palatine or infratemporal fossa areas
 other sites included tongue, buccal mucosa, maxillary sinus and the
subcutaneous tissues of the neck.
 parotid ,submandibularglands, parapharyngeal space as well as the
posterior or anterolateral cervical regions

Size:
small cysts reaching up to 1–5 cm in diameter/year, enlarge
progressively.

http://www.ijdentistry.com/article.asp?i
ssn=0975
962X;year=2015;volume=6;issue=3;sp
age=157;epage=160;aulast=Lavanya
Clinical feature
Intraoral hydatid cyst: A rare case report
Ravi Kiran Alaparthi, Samatha
Yelamanchili, Purnachandrarao Naik
Nunsavathu, Udaya Sode
(pub med)
http://www.ijdentistry.com/article.asp?iss
n=0975
962X;year=2015;volume=6;issue=3;spag
e=157;epage=160;aulast=Lavanya
 :SIGN AND SYMPTOMS
 Hydatid cysts are characteristically slow growing and asymptomatic
benign cystic lesions.

 expression of symptoms depends on the location, pressure, and size of the

enlarging cyst.

 Patients usually show generalized

urticaria and pruritus ,
which results from sensitivity caused
due to echinococcal antigen from the cyst.

 hydatid cyst presents as a solitary, unilocular cyst, and 20–30% of cases

may have several cysts in one organ or a single cyst in multiple organs.
:DENTAL EFFECT AND FEATURE

Not associated with pain or

difficulty while chewing or
.during other functional activities
:DIAGNOSIS AND RADIOGRAPHIC FEATURE
The diagnosis of this condition can be made by :
 histopathology
 Panoramic radiography (no changes)
 fine needle aspiration cytology (FNAC) findings were suggestive of
inflammatory lesion
 Computed tomography scan,
 ultrasonic scanning
 magnetic resonance imaging detects the cystic lesion in soft tissue areas and
daughter cysts precisely.

 At present, CT and USG (ultrasonography) are the most precious imaging

techniques early in the disease process and frequently reveal one or more
simple appearing cysts of varying sizes that are surrounded by either a thin,
well-circumscribed wall or, less often, by a slightly thickened irregular wall.

 USG is helpful, particularly in the early stages, when the lesion is cystic, in
detecting daughter cysts, hydatid sand, and hydatid membranes.
According to recently published reports, MRI can
differentiate parasitic, nonparasitic, or traumatic cysts by
demonstrating “low-signal intensity rim,” the so-called rim
sign, which has been described as characteristic of
hydatidosis.

Blood investigations show eosinophilia in 30% of patients.

Fine‑needle aspiration biopsy may show hooklets, scolices or
remnants of the laminated membrane. Serological tests such
as ELISA, indirect hemagglutination test, latex agglutination,
immunoelectrophoresis, and Casoni skin tests are more
sensitive where in, a decrease in the titer indicates
resolution and increase in titer indicates recurrence of
Echinococcosis .
Radiographic
feature

Intraoral hydatid cyst: A rare case report Ravi Kiran

Alaparthi, Samatha Yelamanchili, Purnachandrarao
Naik Nunsavathu, Udaya Sode
(pub med)

Hydatid cyst in the upper two

third of the left lung
:HISTOPATHOLOGICAL FEATURE
The mature cyst consists of three layers:
1_ outer layer of host origin .
2_ two inner layers of parasitic origin.

 Outer host layer :consists of

o fibrous tissue
o Infiltrated chronic inflammatory cells, eosinophils and giant cells.

 The intermediate layer /

Is white, non-nucleated, and consists of numerous delicate laminations.
It usually shrinks away from the outer fibrous layer when the tension
within the cyst is relieved .

 The inner, nucleated germinal layer .

Histopathological feature

Cysts of the Oral and

Maxillofacial Regions Fourth
edition (Mervyn Shear &
Paul Speight)
 DIFFERENTIAL DIAGNOSIS
If no primary or hydatid cyst in other sites
of the body have been found, the diagnosis of hydatid
cyst localized to head and neck is pretty challenging
for the clinicians.

Differential diagnoses of intramuscular calcification,

rhabdomyoma, and solitary neurofibroma
were considered.(if the cyst in the cheek)
 TREATMENT
 Surgical removal of cyst is the most common treatment,
And in a few cases in combination with chemotherapy.
 Chemotherapy is usually followed in lesions that are inaccessible
for surgery and patients with multiple organ involvement..
 Scolicidal agents or a combination of praziquantel, albendazole,

and mebendazole are used against E. granulosus.

 Albendazole postoperatively for 1‑month is usually suggested
according to the WHO guidelines.
 PROGNOSIS
 The prognosis is excellent in cases treated by
removal of cyst totally without rupture.

 Spillage of the cystic content, presence of

daughter cysts, and leftover endocyst in the
operated field are few reasons for the
recurrence of the cyst
:CYSTICERCUS CELLULOSAE DEFINITION
 Cysticercosis is a potentially fatal parasitic
disease that rarely involves the oral region in
humans .
 Cysticercosis is the result of infection with the
larval stage of the tape-worm, Taeniasolium (T.
solium ).

 It usually affect s subcutaneous tissue , brain,

muscle, heart, liver, lungs and the eyes .
: ETIOLOGY AND PATHOLOGY
Ingestion of inadequately cooked pork 

containing cycticerci leads to infection i n

human being (the
definitive host ) and the human can
act as (intermediate host) through
accidental ingestion of T.Solium egg (faecal-oral 

route)
:CLINICAL FEATURE
 Age / age range of 3–70 years and mean age
of 22 years.
 Sex / male : female ratio was 1 : 1

 Site /the most common site tongue, followed

by buccal mucosa and lips

few cases with multiple oral lesions.
 Sign and symptom /

Asymptomatic cystic swelling or nodul

ecovered by normal appearing mucosa.
:HISTOPATHOLOGICAL FRATURE
 examination of Cysticercus cellulosae shows
a dense fibrous capsule derived from host tissue.
 the capsule contain dense inflammatory cell
infiltrate consisting of : lymphocytes, plasma
cells and histiocytes.
 the inner aspect of this fibrous capsule

consists of a dense aggregation of eosinophil

and neutrophil polymorphonuclear leucocytes.
 A few foci of dystrophic calcification are

present in this capsule .

 Within the fibrous capsule is a delicate
double-layered membrane consisting of /
1_ outer acellular hyaline eosinophilic layer.
2_ inner,sparsely cellular layer.

 The cyst lies within this membrane and

contains the larval form of T. solium .
Cysts of the Oral and Maxillofacial Regions Fourth edition
Mervyn Shear &Paul Speight
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511908/pdf/
12663_2015_Article_745.pdf
 DENTAL EFFECT
 Cysticercus cellulosaeis harmless in the oral
Tissues
But, localisation in the brain, heart valves and
orbit occurs and produces important
functional derangements.
:ASSOCIATED WITH SYNDROME OR DISEASE

systemic complications are not commonly

detected in patients with oral lesions .
:DIAGNOSIS AND RADIOGRAPHIC FEATURE
 Conventional radiographs are useful for the detection of calcification in
muscles.

 radiodense elongated images of the calcified cysticerci may appear on

any radiograph of the soft tissues of the body.

 In the head and neck region the locations of calcified cysticerci include
muscles of mastication and facial expression, the suprahyoid muscle
and the posterior cervical, the tongue, buccal mucosa or lip.

 They are viewed as multiple well defined elliptical radiopacities

resembling grains of rice.

 Computed tomography (CT) and magnetic resonance imaging (MRI)

have greatly improved the accuracy of diagnosis of cysticercosis.
RADIOGRAPHIC
:COMPLICATION
 invasion of the central nervous system,
inparticular when paranchymal neuro
cysticerci die years after infection, resulting in
strong inflammatory reac tion that leads to
 epilepti c sei zures.
.DIFFERENTIAL DIAGNOSIS
 Differential diagnosis depend s on the location o f the lesion
 Nodules on the lips and cheek may be consider ed as

fibroma, lipoma, mucocele, pyogenic granuloma or

pleomorphic adenoma.
 Nodules on the tongue may be considered as pyogenic granu

loma, fibroma, granular cell tumour ,or rhabdomyoma .

but ,Accordi ng to Wilson et al. oral cysticerci are firm nodules
on palpation because of their intraluminal pressure and
therefore neither lipoma nor hemangioma should be
considered as clinical possi bilities
:TREATMENT
 Treatment cyst is by surgical removal if
possible, before systemic treatment.
 The systemic treatment of cysticercosis is with
praziquantel, albendazole or metrifonate
Cysts of the Oral and Maxillofacial Regions Fourth edition
Mervyn Shear
Paul Speight
 Trichinosis
Definition:
It is caused by consuming undercooked or raw meat (usually pork). Trichinella spiralis
species is the common cause of human disease by eating raw or undercooked pork.
Although, other mammals like wild carnivores and horses can be reservoirs of
infection
Etiology (causes):
Trichinosis is a parasitic disease caused by eating meat that has not been
thoroughly cooked and contains cysts (larvae, or immature worms) of Trichinella
spiralis. This parasite can be found in pork, bear, walrus, fox, rat, horse, and lion.
Wild animals, especially carnivores (meat eaters) or omnivores (animals that eat
both meat and plants), should be considered possible sources of roundworm
disease. Domestic meat animals raised specifically for eating under US Department
of Agriculture (government) guidelines and inspection can be considered safe. For
this reason, trichinosis is rare in the United States, but it is a common infection
worldwide.
When a person eats meat from an infected animal, trichinella cysts break open in
the intestine and grow into adult roundworms. The roundworms produce other
worms that move through the gut wall and into the bloodstream. The worms invade
muscle tissues, including the heart and diaphragm (the breathing muscle under the
lungs). They can also infect the lungs and brain. The cysts remain alive for years.
Initial signs and symptoms:
You swallow trichinella larvae encased in a cyst. Your digestive juices dissolve the cyst,
releasing the parasite into your body. The larvae then penetrate the wall of the small
intestine, where they mature into adult worms and mate. At this stage, you may
experience:
Diarrhea
Abdominal pain
Fatigue
Nausea and vomiting

Later signs and symptoms:

About a week after infection, the adult female worms produce larvae that go through
the intestinal wall, enter your bloodstream, and eventually burrow into muscle or other
tissue. This tissue invasion can cause:
High fever
Muscle pain and tenderness
Swelling of the eyelids or face
Weakness
Headache O'Neill DS, Baquis G, Moral L.
Sensitivity to light Infectious myositis. A tropical
disease steals out of its zone.
Pink eye (conjunctivitis) Postgrad Med. 1996 Aug.
100(2):193-4, 199-200.
[Medline].
Dental effect
Trichinella spiralis is a parasite which is usually seen in pork-eaters. Most of the
trichinosis infections cause little or no symptoms. We report a rare case of a middle
aged North Indian male who presented with a painless ulcer in right buccal mucosa
which was biopsied and reported as squamous cell carcinoma. Wide local excision was
done subsequently which showed encysted larvae of Trichinella spiralis in the deeper
skeletal muscle bundles. This article supports the carcinogenic potential of trichinosis
and suggests timely work-up and treatment of the parasite.

Bruce RA. Trichinosis associated with oral squamous cell

carcinoma: a report of 3 cases. J Oral Surg. 1975;33(2):136–41.
[PubMed] [Google Scholar]
Exams and Tests
Tests to diagnose this condition include:
1) Blood tests such as complete blood count (CBC), eosinophil count (a type of
white blood cell), antibody test, and creatine kinase level (an enzyme found in
muscle cells)
2) Muscle biopsy to check for worms in the muscle

Radiological feature
There is no definitive laboratory test with easy availability to the emergency physician.
CBC reveals eosinophilia in virtually all patients, though it does not develop until 2-6
weeks following ingestion of infected meat when larvae pass out of the intestines. Of
note, eosinopenia has been noted to be associated with more severe infections and an
early fall in eosinophils with a poorer outcomes
Prevention
The best defense against trichinosis is proper food preparation. Follow these tips to avoid
trichinosis:
Avoid undercooked meat. Be sure whole cuts of meat other than poultry and wild game
are cooked to an internal temperature of 145 F (63 C) throughout, and don't cut or eat
the meat for at least three minutes after you've removed it from the heat. Cook ground
pork and beef to at least 160 F (71 C). They can be eaten immediately after cooking.
Using a meat thermometer is the best way to ensure the meat is thoroughly cooked.
Avoid undercooked wild game. For both whole cuts and ground varieties, cook to an
internal temperature of at least 160 F (71 C).
Avoid undercooked poultry. For whole cuts and ground varieties, cook to a temperature
of at least 165 F (74 C). For whole cuts, let the poultry sit for three minutes before cutting
or eating.
Have wild-animal meat frozen or irradiated. Irradiation will kill parasites in wild-animal
meat, and deep-freezing for three weeks kills trichinella in some meats. However,
trichinella in bear meat does not die by freezing, even over a long period. Neither
irradiation nor freezing is necessary if you ensure that the meat is thoroughly cooked.
Know that other processing methods don't kill parasites. Other methods of meat
processing or preserving, such as smoking and pickling, don't kill trichinella parasites in
infected meat.
Clean meat grinders thoroughly. If you grind your own meat, make sure the grinder is
cleaned after each use
Complications
Myocarditis
Pneumonitis
Secondary bacterial pneumonia
Nephritis
Chronic diarrhea
Neurotrichinellosis

Differential Diagnosis
Gastroenteritis - viral or bacterial
Polymyositis and dermatomyositis (autoimmune)
Periorbital cellulitis
Eosinophilia-myalgia syndrome
Eosinophilia can be present other helminthic infections like fasciola, schistosomiasis,
toxocariasis, cysticercosis, visceral larva migrans, and sarcocystosis
Treatment
The clinical course of trichinellosis is self-limited in most cases, and it is
uncomplicated.
Mild infections are treated symptomatically with antipyretics and anti-inflammatory
agents.
Trichinella infection with systemic complications is treated with antiparasitic agents
and corticosteroids.[18]
Albendazole 500mg twice daily given orally for 10 to 14 days (or) Mebendazole 200 to
400 mg thrice daily for 3 days, then 400 to 500 mg three times daily for 10 days.
Severe cases may require coadministration with prednisone at a dose of 30 to 60mg
daily for a total of 10 to 14 days.
Albendazole and mebendazole are not considered safe in pregnant women and
children less than or equal to 2 years of age. Specialist consultation is necessary in
these cases and risk, and weighing the benefits vs. risks is necessary before
administering the drug. The World Health Organization's recommendations are that
pregnant women can get antihelminthic medications (mebendazole, albendazole,
pyrantel or levamisole) after their first trimester.
Cardiac monitoring is necessary
REFERENCES
 Wanjari SP, Patidar KA, Parwani RN, and Tekade SA
Oral cysticercosis: a clinical dilemma ,2013
doi: 10.1136/bcr-2012-007482
 Alaparthi R K, Yelamanchili S, Nunsavathu P N,and Sode U
Intraoral hydatid cyst: A rare case report ,2015
Volume : 27 , Issue : 3  ,Page : 457-460
 Lavanya R M, Kamath VV, Komali Y, Krishnamurthy S
Hydatid cyst of the buccal mucosa: An unusual presentation,2015
Volume : 6  Issue : 3   Page : 157-160

 Mervyn shear , paul m. Speight . Cysts of oral and maxillofacial regions .

Fourth edition . Britich library .black well munksgaard . 2007
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Thank