ABSTRACT
BACKGROUND: Tolosa-Hunt syndrome (THS) is characterized by painful ophthalmoplegia caused by idiopathic granulomatous inflammation involving the cavernous sinus region. Patients respond well to steroid therapy. THS is included in the differential diagnosis of cavernous sinus syndrome, so it is important to fully exclude other lesions in this area before treatment, otherwise steroid treatment may lead to fatal outcomes. Here we describe a patient who initially presented with symptoms that simulated THS symptoms and developed recurrent alternating painful ophthalmoplegia during follow-up, and the patient was finally diagnosed with cavernous sinusitis caused by bacterial sphenoid sinusitis. CASE PRESENTATION: A 34-year-old woman presented with left painful ophthalmoplegia. Magnetic resonance imaging (MRI) revealed abnormal signals in the left cavernous sinus area, and these abnormal signals were suspected to be THS. After steroid treatment, the patient obtained pain relief and had complete recovery of her ophthalmoplegia. However, right painful ophthalmoplegia appeared during the follow-up period. MRI showed obvious inflammatory signals in the right cavernous sinus and right sphenoid sinus. Then nasal sinus puncture and aspiration culture were performed, and the results showed a coagulase-negative staphylococcus infection. After antibiotic treatment with vancomycin, the painful ophthalmoplegia completely resolved, and the neurological examination and MRI returned to normal. CONCLUSION: Some other causes of painful ophthalmoplegia also fulfill the diagnostic criteria for THS in the International Classification of Headache Disorders third edition (ICHD-3) and respond well to steroid therapy. Early diagnosis of THS may be harmful to patients, and clinicians should exercise great caution when dealing with similar cases without a biopsy. Using "cavernous sinus syndrome" instead of "Tolosa-Hunt syndrome" as a diagnostic category may provide a better clinical thinking for etiological diagnosis.
Subject(s)
Ophthalmoplegia , Sinusitis , Sphenoid Sinusitis , Humans , Female , Adult , Sphenoid Sinusitis/diagnosis , Sphenoid Sinusitis/diagnostic imaging , Magnetic Resonance Imaging , Sinusitis/complications , Ophthalmoplegia/diagnosis , Steroids/therapeutic useABSTRACT
BACKGROUND: Covid-19 has serious sequelae that may be poorly understood, underreported, and, as a result, not diagnosed promptly, such as variations in clinical manifestations of hyperinflammation among people infected with SARS-CoV-2. ophthalmoplegia can be one of these manifestations. METHODS: We are reporting a 55-year-old male patient with unilateral diplopia considering it as a case of multisystem inflammatory syndrome in adults. We also reviewed the literature systematically for the previously reported studies/cases with third, fourth and sixth cranial nerve palsies due to or after Covid-19. RESULTS: The literature search yielded 17 studies reporting 29 patients. 71.4% of the patients were males with a mean age of 42.23 years. Ophthalmological symptoms took 9.7 days to appear after the respiratory involvement. All patients had diplopia as part of their visual symptoms. 41.4% of the patients had unilateral sixth nerve palsy, 24% had bilateral sixth nerve involvement, 17% had fourth nerve involvement, and 27.6% had third nerve involvement. CONCLUSION: Ophthalmoplegia is considered presenting symptom of Covid-19. Further research is needed to detect all neuro-ophthalmological manifestations of Covid-19.
Subject(s)
Abducens Nerve Diseases , COVID-19 , Cranial Nerve Diseases , Oculomotor Nerve Diseases , Ophthalmoplegia , Male , Adult , Humans , Middle Aged , Female , Oculomotor Nerve Diseases/etiology , COVID-19/complications , SARS-CoV-2 , Abducens Nerve Diseases/etiology , Abducens Nerve Diseases/diagnosis , Diplopia/etiology , Ophthalmoplegia/diagnosis , Ophthalmoplegia/etiology , Cranial Nerve Diseases/diagnosisABSTRACT
Internuclear ophthalmoplegia (INO) is a neuro-ophthalmic disorder caused by damage in the medial longitudinal fasciculus between the third and sixth cranial nerve nuclei. We present a 4-year-old female diagnosed with INO triggered by coronavirus disease 2019 (COVID-19) infection. The patient had history of neonatal meningitis with hydrocephalus without history of surgical intervention. To the best of our knowledge, this is the first case with combined COVID-19 and chronic hydrocephalus as an etiology for INO in a child. COVID-19 may trigger neurological manifestations as INO in susceptible cases.
Subject(s)
COVID-19 , Hydrocephalus , Ocular Motility Disorders , Ophthalmoplegia , COVID-19/complications , Child , Child, Preschool , Female , Humans , Hydrocephalus/complications , Hydrocephalus/diagnosis , Infant, Newborn , Ocular Motility Disorders/diagnosis , Ophthalmoplegia/diagnosisABSTRACT
INTRODUCTION: Miller Fisher syndrome (MFS) is a rare variant of Guillain-Barre syndrome characterized by ataxia, areflexia, and ophthalmoplegia. We present a case of MFS following Pfizer COVID-19 vaccine. CASE PRESENTATION: A previously healthy 24-year-old female presented with binocular horizontal diplopia 18 days after receiving the first dose of Pfizer COVID-19 vaccine (Comirnaty®). Anti-ganglioside testing revealed positive anti-GQ1b antibodies. Intravenous immunoglobulins were administered, in a dose of 2 g per kg of body weight over 5 days. On a follow-up exam 3 weeks after the treatment, clinical improvement was noted with normal bulbomotor examination. CONCLUSION: Patients with acute ophthalmoplegia occurring after COVID-19 vaccination should be screened for the presence of anti-GQ1b antibody. If the antibody is present, intravenous immunoglobulin should be administered as it may hasten clinical improvement.
Subject(s)
COVID-19 , Miller Fisher Syndrome , Ophthalmoplegia , Adult , COVID-19 Vaccines , Female , Gangliosides , Humans , Miller Fisher Syndrome/chemically induced , Miller Fisher Syndrome/diagnosis , Ophthalmoplegia/diagnosis , SARS-CoV-2 , Young AdultSubject(s)
COVID-19/complications , Mucormycosis/diagnosis , Rhizopus oryzae/isolation & purification , Adult , COVID-19/immunology , Exophthalmos/diagnosis , Fatal Outcome , Humans , Immunocompromised Host , Male , Mucormycosis/drug therapy , Mucormycosis/microbiology , Mucormycosis/surgery , Ophthalmoplegia/diagnosis , Rhizopus oryzae/physiology , COVID-19 Drug TreatmentABSTRACT
A 60-year-old man recently admitted for bipedal oedema, endocarditis and a persistently positive COVID-19 swab with a history of anticoagulation on rivaroxaban for atrial fibrillation, transitional cell carcinoma, cerebral amyloid angiopathy, diabetes and hypertension presented with sudden onset diplopia and vertical gaze palsy. Vestibulo-ocular reflex was preserved. Simultaneously, he developed a scotoma and sudden visual loss, and was found to have a right branch retinal artery occlusion. MRI head demonstrated a unilateral midbrain infarct. This case demonstrates a rare unilateral cause of bilateral supranuclear palsy which spares the posterior commisure. The case also raises a question about the contribution of COVID-19 to the procoagulant status of the patient which already includes atrial fibrillation and endocarditis, and presents a complex treatment dilemma regarding anticoagulation.