ABSTRACT
PURPOSE OF REVIEW: Describe the range of infectious causes of ocular motor neuropathies, from common presentations to unusual manifestations of diseases less frequently seen in the developed world. Provide information on recent developments in diagnostic testing for pathogens that may cause ocular motor neuropathies. RECENT FINDINGS: Antigen detection in serum or CSF has improved the diagnosis of cryptococcal disease. Cartridge PCR testing for tuberculosis has increased diagnostic accuracy, though tuberculous meningitis remains difficult to diagnose. Rapid, multiplex PCR and unbiased sequencing allow for diagnosis of a wider range of organisms. SUMMARY: Infectious ocular motor neuropathies can occur anywhere along the length of cranial nerves III, IV, and VI. Characteristic clinical findings and imaging can be used to localize infections. Infectious causes may have characteristic clinical, laboratory, or imaging findings, but must still be carefully separated from inflammatory or neoplastic conditions.
Subject(s)
Abducens Nerve Diseases/microbiology , Eye Infections, Bacterial/microbiology , Oculomotor Nerve Diseases/microbiology , Trochlear Nerve Diseases/microbiology , Abducens Nerve Diseases/epidemiology , Cavernous Sinus Thrombosis/epidemiology , Eye Infections, Bacterial/epidemiology , Humans , Infectious Encephalitis/epidemiology , Oculomotor Nerve Diseases/epidemiology , Osteomyelitis/epidemiology , Skull Base/pathology , Trochlear Nerve Diseases/epidemiologyABSTRACT
A 69-year-old woman was admitted to our hospital with a fever, dizziness, and headache caused by Neisseria meningitidis. After ceftriaxone was administered, she suddenly developed bilateral oculomotor nerve palsy. Intra-orbital magnetic resonance imaging using appropriate sequences revealed that her bilateral third intracranial nerves were enlarged and enhanced. She achieved complete recovery by two months after additional short-term treatment with intravenous immunoglobulin and methylprednisolone. Although intracranial nerve disorders that result from bacterial meningitis are most frequently reported in children, it is noteworthy that it can also cause focal intracranial nerve inflammation with ophthalmoparesis in N. meningitidis infection in adults.
Subject(s)
Meningitis, Meningococcal/complications , Oculomotor Nerve Diseases/microbiology , Acute Disease , Aged , Drug Therapy, Combination , Female , Glucocorticoids/therapeutic use , Headache/diagnostic imaging , Headache/microbiology , Humans , Immunoglobulins, Intravenous/therapeutic use , Magnetic Resonance Imaging , Meningitis, Meningococcal/diagnostic imaging , Meningitis, Meningococcal/therapy , Methylprednisolone/therapeutic use , Oculomotor Nerve/diagnostic imaging , Oculomotor Nerve Diseases/diagnostic imaging , Oculomotor Nerve Diseases/therapySubject(s)
Oculomotor Nerve Diseases/diagnosis , Tuberculosis, Meningeal/diagnosis , Antitubercular Agents/therapeutic use , Diagnosis, Differential , Diplopia/diagnosis , Diplopia/etiology , Humans , Immunocompetence , Male , Oculomotor Nerve Diseases/drug therapy , Oculomotor Nerve Diseases/etiology , Oculomotor Nerve Diseases/microbiology , Tuberculosis, Meningeal/complications , Tuberculosis, Meningeal/drug therapy , Young AdultABSTRACT
Isolated brain stem tuberculoma constitutes about 5% of all intracranial tuberculomas. A case of isolated inferior rectus palsy with downbeat nystagmus due to presumed midbrain tuberculoma in an immunocompetent patient is described here. This report documents a rare entity of a combination of partial third nerve palsy with pupil involvement along with downbeat nystagmus.
Subject(s)
Mesencephalon/pathology , Nystagmus, Pathologic/diagnosis , Oculomotor Nerve Diseases/diagnosis , Tuberculoma, Intracranial/diagnosis , Antitubercular Agents/therapeutic use , Drug Combinations , Female , Humans , Magnetic Resonance Imaging , Nystagmus, Pathologic/drug therapy , Nystagmus, Pathologic/microbiology , Oculomotor Nerve Diseases/drug therapy , Oculomotor Nerve Diseases/microbiology , Tuberculoma, Intracranial/drug therapy , Tuberculoma, Intracranial/microbiology , Young AdultSubject(s)
Lyme Disease/diagnosis , Lyme Disease/drug therapy , Oculomotor Nerve Diseases/drug therapy , Oculomotor Nerve Diseases/pathology , Anti-Bacterial Agents/therapeutic use , Ceftriaxone/therapeutic use , Diplopia/etiology , Exanthema/etiology , Fatigue/etiology , Humans , Lyme Disease/complications , Magnetic Resonance Imaging , Male , Middle Aged , Myalgia/etiology , Oculomotor Nerve Diseases/microbiologySubject(s)
Blepharoptosis/diagnosis , Blepharoptosis/microbiology , Oculomotor Nerve Diseases/diagnosis , Oculomotor Nerve Diseases/microbiology , Streptococcal Infections/diagnosis , Streptococcal Infections/microbiology , Anti-Bacterial Agents/therapeutic use , Blepharoptosis/drug therapy , Diagnosis, Differential , Humans , Infant , Male , Oculomotor Nerve Diseases/drug therapy , Streptococcal Infections/drug therapy , Streptococcus pneumoniae/isolation & purificationABSTRACT
BACKGROUND: The differential diagnosis of isolated oculomotor nerve paresis ranges from benign to potentially lethal pathologies. Intracranial tuberculosis (TB), as in the case of this patient, carries a high morbidity and mortality. Early diagnosis is crucial to improve patient outcomes. CASE REPORT: We present the case of a 46-year-old man with a chief complaint of 5 days of diplopia. His examination was remarkable for right inferolateral exotropia and weakness of the right medial rectus. Due to the neurologic findings, we obtained a computed tomography brain scan, which revealed a ring-enhancing lesion within the central midbrain with vasogenic edema causing mass effect on the cerebral aqueduct. Further evaluation revealed tuberculosis (TB) as the underlying etiology. He was placed on steroids and a four-drug anti-TB regimen with resultant improvement of his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intracranial tuberculoma can present with an isolated oculomotor nerve paresis in the absence of pulmonary or systemic symptoms. This case emphasizes the importance of maintaining a broad differential when investigating isolated oculomotor nerve paresis.
Subject(s)
Oculomotor Nerve Diseases/microbiology , Paresis/microbiology , Tuberculoma, Intracranial/complications , Humans , Male , Middle Aged , Tomography, X-Ray Computed , Tuberculoma, Intracranial/diagnosis , Tuberculoma, Intracranial/drug therapyABSTRACT
Brucellosis is a zoonotic infectious disease that is common around the world. Its clinical course demonstrates great diversity as it can affect all organs and systems. However, the central nervous system is rarely affected in the pediatric population. Neurobrucellosis is most frequently observed with meningitis and has numerous complications, including meningocephalitis, myelitis, cranial nerve paralyses, radiculopathy, and neuropathy. Neurobrucellosis affects the second, third, sixth, seventh, and eighth cranial nerves. Involvement of the oculomotor nerves is a very rare complication in neurobrucellosis although several adult cases have been reported. In this article, we present the case of a 9-year-old girl who developed unilateral nerve paralysis as a secondary complication of neurobrucellosis and recovered without sequel after treatment. This case is notable because it is a very rare, the first within the pediatric population. Our article emphasizes that neurobrucellosis should be considered among the distinguishing diagnoses in every case that is admitted for nerve paralysis in regions where Brucella infection is endemic.
Subject(s)
Brucellosis/complications , Central Nervous System Bacterial Infections/complications , Oculomotor Nerve Diseases/etiology , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/therapeutic use , Brucella , Brucellosis/drug therapy , Ceftriaxone/administration & dosage , Ceftriaxone/therapeutic use , Child , Drug Therapy, Combination , Female , Humans , Oculomotor Nerve Diseases/microbiology , Rifampin/administration & dosage , Rifampin/therapeutic use , Trimethoprim, Sulfamethoxazole Drug Combination/administration & dosage , Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic useSubject(s)
Aneurysm, Infected/microbiology , Aspergillosis/complications , Carotid Artery, Internal , Orbital Diseases/microbiology , Sphenoid Sinusitis/microbiology , Abducens Nerve Diseases/microbiology , Aneurysm, Infected/diagnosis , Aneurysm, Infected/surgery , Aspergillosis/diagnosis , Blepharoptosis/microbiology , Fatal Outcome , Humans , Male , Middle Aged , Oculomotor Nerve Diseases/microbiology , Orbital Diseases/diagnosis , Orbital Diseases/surgery , Rupture, Spontaneous/microbiology , Sphenoid Sinusitis/diagnosis , Sphenoid Sinusitis/surgery , Syndrome , Trigeminal Nerve Diseases/microbiology , Trochlear Nerve Diseases/microbiology , Vision, Low/microbiologyABSTRACT
We report a rare case of oculomotor nerve palsy and choroidal tuberculous granuloma associated with tuberculous meningoencephalitis. A 15-year-old male visited our hospital for an acute drop of the left eyelid and diplopia. He has been on anti-tuberculous drugs (isoniazid, rifampin) for 1 year for his tuberculous encephalitis. A neurological examination revealed a conscious clear patient with isolated left oculomotor nerve palsy, which manifested as ptosis, and a fundus examination revealed choroidal tuberculoma. Other anti-tuberculous drugs (pyrazinamide, ethambutol) and a steroid (dexamethasone) were added. After 3 months on this medication, ptosis of the left upper eyelid improved and the choroidal tuberculoma decreasedin size, but a right homonymous visual field defect remained. When a patient with tuberculous meningitis presents with abrupt onset oculomotor nerve palsy, rapid re-diagnosis should be undertaken and proper treatment initiated, because the prognosis is critically dependent on the timing of adequate treatment.
Subject(s)
Choroid Diseases/microbiology , Meningoencephalitis/microbiology , Mycobacterium tuberculosis/isolation & purification , Oculomotor Nerve Diseases/microbiology , Tuberculoma/microbiology , Tuberculosis, Meningeal/microbiology , Adolescent , Antitubercular Agents/therapeutic use , Blepharoptosis/diagnosis , Blepharoptosis/drug therapy , Blepharoptosis/microbiology , Choroid Diseases/diagnosis , Choroid Diseases/drug therapy , Dexamethasone/therapeutic use , Drug Therapy, Combination , Ethambutol/therapeutic use , Glucocorticoids/therapeutic use , Humans , Magnetic Resonance Imaging , Male , Meningoencephalitis/diagnosis , Meningoencephalitis/drug therapy , Oculomotor Nerve Diseases/diagnosis , Oculomotor Nerve Diseases/drug therapy , Pyrazinamide/therapeutic use , Radiography, Thoracic , Tuberculoma/diagnosis , Tuberculoma/drug therapy , Tuberculosis, Meningeal/diagnosis , Tuberculosis, Meningeal/drug therapy , Tuberculosis, Ocular/diagnosis , Tuberculosis, Ocular/drug therapy , Tuberculosis, Ocular/microbiology , Visual Field Tests , Visual FieldsSubject(s)
Aspergillosis/complications , Aspergillosis/pathology , Oculomotor Nerve Diseases/microbiology , Oculomotor Nerve Diseases/pathology , Sphenoid Sinusitis/microbiology , Sphenoid Sinusitis/pathology , Aged , Antifungal Agents/therapeutic use , Aspergillosis/physiopathology , Blepharoptosis/microbiology , Blepharoptosis/pathology , Blepharoptosis/physiopathology , Diplopia/microbiology , Diplopia/pathology , Diplopia/physiopathology , Humans , Intracranial Hypertension/complications , Intracranial Hypertension/microbiology , Intracranial Hypertension/pathology , Magnetic Resonance Imaging , Male , Ocular Motility Disorders/microbiology , Ocular Motility Disorders/pathology , Ocular Motility Disorders/physiopathology , Oculomotor Nerve/anatomy & histology , Oculomotor Nerve/microbiology , Oculomotor Nerve/pathology , Oculomotor Nerve Diseases/physiopathology , Recovery of Function/physiology , Remission, Spontaneous , Sphenoid Sinus/anatomy & histology , Sphenoid Sinus/microbiology , Sphenoid Sinus/pathology , Sphenoid Sinusitis/physiopathology , Subarachnoid Space/microbiology , Subarachnoid Space/pathology , Subarachnoid Space/physiopathology , Treatment OutcomeSubject(s)
Meningitis, Cryptococcal/complications , Oculomotor Nerve Diseases/microbiology , Peripheral Nervous System Diseases/microbiology , Humans , Intracranial Hypertension/diagnosis , Ischemia/diagnosis , Ischemia/microbiology , Microcirculation/pathology , Microcirculation/physiopathology , Neuritis/diagnosis , Neuritis/microbiology , Oculomotor Nerve/blood supply , Oculomotor Nerve/pathology , Oculomotor Nerve/physiopathology , Oculomotor Nerve Diseases/physiopathology , Peripheral Nervous System Diseases/physiopathology , Vasculitis/diagnosis , Vasculitis/microbiologySubject(s)
Brain Abscess/diagnosis , Brain Stem Infarctions/diagnosis , Ethmoid Sinus/pathology , Meningitis, Bacterial/diagnosis , Motor Cortex/physiopathology , Oculomotor Nerve Diseases/diagnosis , Brain Abscess/microbiology , Brain Abscess/physiopathology , Diagnosis, Differential , Empyema/diagnosis , Empyema/microbiology , Empyema/physiopathology , Encephalitis/diagnosis , Encephalitis/microbiology , Encephalitis/physiopathology , Fatal Outcome , Humans , Magnetic Resonance Imaging , Male , Meningitis, Bacterial/microbiology , Middle Aged , Motor Cortex/microbiology , Motor Cortex/pathology , Oculomotor Nerve/microbiology , Oculomotor Nerve/pathology , Oculomotor Nerve/physiopathology , Oculomotor Nerve Diseases/microbiology , Oculomotor Nerve Diseases/physiopathology , Paranasal Sinus Diseases/complications , Paranasal Sinus Diseases/diagnosis , Paresis/diagnosis , Paresis/microbiology , Paresis/physiopathology , Streptococcal Infections/complicationsSubject(s)
AIDS-Related Opportunistic Infections/complications , Meningitis, Cryptococcal/complications , Oculomotor Nerve Diseases/etiology , AIDS-Related Opportunistic Infections/drug therapy , Abducens Nerve/microbiology , Adult , Amphotericin B/therapeutic use , Antifungal Agents/therapeutic use , Fatal Outcome , Flucytosine/therapeutic use , Humans , Ischemia/etiology , Male , Meningitis, Cryptococcal/drug therapy , Oculomotor Nerve/blood supply , Oculomotor Nerve/microbiology , Oculomotor Nerve Diseases/microbiology , Pulmonary Embolism/etiology , Vasculitis/etiology , Vasculitis/microbiologySubject(s)
Bacteremia/complications , Esotropia/etiology , Oculomotor Nerve Diseases/complications , Pneumococcal Infections/complications , Bacteremia/microbiology , Eye Movements , Humans , Infant , Male , Oculomotor Nerve Diseases/microbiology , Oculomotor Nerve Diseases/surgery , Pneumococcal Infections/microbiology , Strabismus/etiology , Strabismus/surgery , Streptococcus pneumoniae/isolation & purificationABSTRACT
Subacute disseminated histoplasmosis is an uncommon entity. Typical neuro-ophthalmologic manifestations are usually secondary to histoplasmomas or encephalitis. A 45-year-old man noted blurred vision while receiving empiric antituberculosis therapy for fever and diffuse granulomatous disease of unknown origin. Vertical-gaze palsy, right horizontal-gaze paresis, and mild right optic neuropathy were found on neuro-ophthalmologic examination. Further questioning revealed a history of frequent contact with fighting cocks from South America. Magnetic resonance images were consistent with multiple hemorrhagic infarcts, areas of inflammation, or both, and cerebral angiography showed changes consistent with vasculitis. A previously obtained biopsy specimen from the duodenum was restained and found to be positive for fungal elements. Serum antigen titers for Histoplasma capsulatum demonstrated evidence of active infection. This case is a rare example of a supranuclear ocular motility disturbance and optic neuropathy secondary to an occlusive vascular process in a patient with subacute disseminated histoplasmosis.
Subject(s)
Histoplasmosis/complications , Oculomotor Nerve Diseases/microbiology , Ophthalmoplegia/microbiology , Tuberculosis/therapy , Diagnostic Errors , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Oculomotor Nerve Diseases/diagnosis , Ophthalmoplegia/diagnosis , Tuberculosis/diagnosisABSTRACT
Listeria monocytogenes rhomboencephalitis is an uncommon complication of L. monocytogenes meningitis. It presents in a typical biphasic pattern characterized by a non-specific prodromal period followed by any combination of asymmetrical, cranial-nerve palsies; cerebellar signs; hemiparesis or hypesthesia; and diminished consciousness. The survival rate is greater than 70% when appropriate antibiotic therapy is initiated early. However, approximately 60 percent of the survivors develop neurological sequelae. We present the case of a 33-year-old woman who developed L. monocytogenes meningitis with subsequent rhomboencephalitis and cranial-nerve palsie, and review the literature on this syndrome.