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A case of oculomotor nerve palsy and choroidal tuberculous granuloma associated with tuberculous meningoencephalitis.

Moon S, Son J, Chang W - Korean J Ophthalmol (2008)

Bottom Line: He has been on anti-tuberculous drugs (isoniazid, rifampin) for 1 year for his tuberculous encephalitis.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea.

ABSTRACT
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.

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Visual field test. A right homonymous upper quadrant defect was noted after four months of added treatment.
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Figure 5: Visual field test. A right homonymous upper quadrant defect was noted after four months of added treatment.

Mentions: However, subsequently, acute drop of left eyelid occurred and brain MRI showed an increase in the size and number of a multifocal granuloma at the brain base, and increased brain swelling at midbrain and left thalamus (Fig. 2b). He was then re-admitted and a neurological examination revealed a clear conscious patient with isolated left oculomotor nerve palsy, which manifested as ptosis of the left upper eyelid (Marginal reflex distance (MRD) : +4 (OD), -1 (OS), Levator muscle function (LF) : 11 mm (OD), 6 mm (OS)) (Table 1) and paralysis of superior rectus and inferior oblique muscles on the left, but with no apparent papillary defect (Fig. 4a). Other cranial nerves were normal and the uncorrected visual acuity was 20/20 in the right eye and 20/20 in the left. Accordingly, it was suspected that his tuberculosis was resistant to isoniazid and rifampin, and thus, pyrazinamide and ethambutol were added; dexamethasone was also injected to reduce brain swelling. After one month on this medication, no restriction in extraocular movement was apparent (Fig. 4b), his diplopia had also disappeared, and drooping of the left upper eyelid was much improved (MRD: +4 (OD), +3 (OS)). Moreover, the choroidal tuberculous granuloma had reduced slightly to 1/2 the optic disc. After 3 months on this treatment ptosis of the left upper eyelid (MRD: +4 (OD), +2.5 (OS), LF: 15 mm (OD), 11 mm (OS)) improved (Table 2) and the choroidal tuberculous granuloma further decreased (Fig. 3b). However, he complained that he could not see the left eyes of people on television, and thus, visual field testing was conducted (Humphrey field analyzer 2: program C30-2), and a right wedge-shaped sector homonymous visual field defect due to lesions of the left lateral geniculate nucleus (Fig. 5).


A case of oculomotor nerve palsy and choroidal tuberculous granuloma associated with tuberculous meningoencephalitis.

Moon S, Son J, Chang W - Korean J Ophthalmol (2008)

Visual field test. A right homonymous upper quadrant defect was noted after four months of added treatment.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2629901&req=5

Figure 5: Visual field test. A right homonymous upper quadrant defect was noted after four months of added treatment.
Mentions: However, subsequently, acute drop of left eyelid occurred and brain MRI showed an increase in the size and number of a multifocal granuloma at the brain base, and increased brain swelling at midbrain and left thalamus (Fig. 2b). He was then re-admitted and a neurological examination revealed a clear conscious patient with isolated left oculomotor nerve palsy, which manifested as ptosis of the left upper eyelid (Marginal reflex distance (MRD) : +4 (OD), -1 (OS), Levator muscle function (LF) : 11 mm (OD), 6 mm (OS)) (Table 1) and paralysis of superior rectus and inferior oblique muscles on the left, but with no apparent papillary defect (Fig. 4a). Other cranial nerves were normal and the uncorrected visual acuity was 20/20 in the right eye and 20/20 in the left. Accordingly, it was suspected that his tuberculosis was resistant to isoniazid and rifampin, and thus, pyrazinamide and ethambutol were added; dexamethasone was also injected to reduce brain swelling. After one month on this medication, no restriction in extraocular movement was apparent (Fig. 4b), his diplopia had also disappeared, and drooping of the left upper eyelid was much improved (MRD: +4 (OD), +3 (OS)). Moreover, the choroidal tuberculous granuloma had reduced slightly to 1/2 the optic disc. After 3 months on this treatment ptosis of the left upper eyelid (MRD: +4 (OD), +2.5 (OS), LF: 15 mm (OD), 11 mm (OS)) improved (Table 2) and the choroidal tuberculous granuloma further decreased (Fig. 3b). However, he complained that he could not see the left eyes of people on television, and thus, visual field testing was conducted (Humphrey field analyzer 2: program C30-2), and a right wedge-shaped sector homonymous visual field defect due to lesions of the left lateral geniculate nucleus (Fig. 5).

Bottom Line: He has been on anti-tuberculous drugs (isoniazid, rifampin) for 1 year for his tuberculous encephalitis.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea.

ABSTRACT
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.

Show MeSH
Related in: MedlinePlus