The worm in the swollen lid: A trichinellosis tale

A 58-year-old male presented with pain and swelling in the right lower lid for 1 month, associated with swelling in the submandibular region. Prior to consultation, he had completed a course of oral antibiotics without improvement and had also undergone an ENT (Otorhinolaryngology) evaluation for maxillary sinusitis. He had a systemic history of abdominal discomfort with diarrhea, fever, and muscle pain three months prior to the onset of ocular symptoms. On examination, best-corrected visual acuity in both eyes was 6/6. An ill-defined preseptal swelling was noted in the medial aspect of the right lower lid with surrounding edema [Fig. 1], and enlarged submandibular and cervical lymph nodes were noted. The lacrimal system, oral, and comprehensive ENT evaluation were normal. A complete blood count (CBC) showed significant eosinophilia (7.8%). A Computed Tomography (CT) scan of the orbit showed preseptal soft tissue thickening in the right lower eyelid, with a small medial nodular soft tissue [Fig. 2]. A provisional diagnosis of an inflammatory mass in the lower eyelid was made. Mass excision and biopsy were performed for conclusive evidence. Intraoperatively, live worm infestation with a surrounding necrotic, inflamed mass was noticed and sent for histopathological examination (HPE) [Fig. 3]. Biopsy confirmed trichinellosis [Figs. 4 and 5]. He was treated with Albendazole 400 mg twice orally for 14 days. The postoperative period was uneventful.Figure 1: Photograph of a 58-year-old male with swelling in the lower medial aspect of the right lower eyelidFigure 2: A non-contrast Computed Tomography (CT) scan of the orbits, in the sagittal section, reveals preseptal soft tissue thickening with nodularity in the medial aspectFigure 3: Specimen displaying necrotic tissue and live wormsFigure 4: The biopsy section shows larvae, each measuring approximately 1.5 mm in size, with a pair of curved hooks at oral end (green arrow), two mandibles (blue line), and a thick chitinous outer wall (black arrow) exhibiting segmentation (artefactual)Figure 5: Necrotic, eosinophil-dominant inflammatory granulation tissue (blue arrow) was present between the muscle fibers of the eyelid (green arrow), containing an encysted larva (yellow circle), without nurse cells and calcificationDiscussion Trichinellosis, mainly by Trichinella spiralis, spreads via undercooked meat. After ingestion, microfilariae excyst, mature in the intestine, then migrate to skeletal muscle via the blood and lymphatic system, encapsulate, and survive for months to years.[1] Fever, myalgia, eyelid edema, eosinophilia, and diarrhea suggest trichinellosis. During the acute stage, vasculitis and perivasculitis symptoms predominate. Early eosinophilia appears before clinical features.[2] Early antihelmintic treatment (Albendazole/Mebendazole) is crucial to prevent long-term damage. Oral steroids can be administered concurrently in severe cases.[1] If surgical excision is planned, the mass should be removed in toto, along with any necrotic and inflammatory tissue. Conclusion Undercooked meat exposure, eyelid and periocular edema, extraocular muscle involvement, vascular lesions, significant eosinophilia, and conclusive muscle biopsy aid in the diagnosis of trichinellosis. A biopsy is essential when there is no improvement despite appropriate medical treatment. We chose to present this case due to its rarity.