Download Morning Report 8.23.16 – Tolosa Hunt

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts

Vision therapy wikipedia, lookup

Idiopathic intracranial hypertension wikipedia, lookup

Eyeglass prescription wikipedia, lookup

Visual impairment due to intracranial pressure wikipedia, lookup

Dry eye syndrome wikipedia, lookup

Human eye wikipedia, lookup

Transcript
Noon Report
8/23/16
Pooya Banankhah
HPI


33 F with no PMH presented with HA, R eye pain, and double vision x 4 days.

4 days prior to admission: R sided severe headache

2 days prior to admission: headache developed into sudden-onset R sided eye pain
10/10, radiating to her R jaw, associated with double vision, and worse with eye
movement.

Also notes periorbital swelling, nausea and chills
Social hx:


No alcohol, tobacco, drugs.
Currently not working. Lives at home with husband.
Family hx:

Non-contributory
Physical Exam

Presenting Vitals:
T: 36.7 °C (Oral) HR: 65 (Monitored) RR: 17 BP: 116 / 67 SpO2: 98%

Physical Exam:

Gen: Anxious but in NAD

HEENT: PERRLA, EOM notable for inability to abduct R eye past midline. Pain w/ lateral and
upward gaze noted in R eye.

Heart: rrr, no murmurs, rubs or gallops

Lungs: ctab, no w/r/c

Ext: warm, well perfused, w/o edema bilaterally

Skin: No lesions or rashes noted.

Neuro: A&Ox3, CN normal except for diplopia present in right eye but not left, EOMI intact
except for inability to abduct right eye past midline, Vision 20/20 in both right and left eye,
otherwise normal neuro exam.
Labs:

CBC: WBC:11.6/ Hgb:14.2/ Hct:42.9/ Plt:350

BMP: Na 136/ K 4.1/ Cl 102/ CO2 102/ BUN 7/ Cr 0.56/ Glu 104
More Labs

ESR 20, CRP 2.8

LDH 110

HgA1c 5.8%

TSH 3.24

UA: small blood, trace leuks, negative nitrites, 4WBC, 2RBC

HIV, RPR, Hep A/B/C panel negative

SPEP: Normal

Serum ACE: normal

SM ab, RNP Ab, Myeloper Ab negative
Imaging

CT Head:


No acute intracranial abnormality.
MRI Brain:

Some very subtle soft tissue thickening and enhancement along the R lateral
cavernous sinus margin extending through the region of R orbital apex

No evidence of demyelinating disease

No acute hemorrhage, mass, fluid collection, infarction

No abnormal parenchymal or leptomeningeal enhancement
Imaging

MRI Orbit:

Enhancing T1 isointense soft tissue extending toward the right orbital apex and to
the origin of the right lateral rectus muscle measuring approximately
8.9x6.8x14.8mm.

No dural tail observed to suggest meningioma

L cavernous sinus unremarkable
Differential Diagnosis
Differential diagnosis:

Tolosa Hunt Syndrome

Sarcoidosis

Lymphoma with meningioma

Periorbital cellulitis

TB

Ophthalmologic migraine

Poorly controlled DM

MS

Myositis

Duanes syndrome (congenital non-
progressive strabismus)

Orbital apex syndrome (CN deficit
due to mass lesion near apex)

Carotid-cavernous fistula or
thrombosis

ICA dissection

SCC

Abscess

Mucormycosis, actinomycosis

GCA

Wegner’s
Lumbar puncture:

RBC 192, WBC 0

Cytology: Rare mature lymphocytes and monocytes. Negative for malignant cells

Flow cytometry: Insufficient sample

CSF Cx and fungal cx negative
Work up

No biopsy done by ophtho:


Meningioma can be diagnosed on imaging and lymphoma can be identified on
cytology from LP
CT Abdomen and thorax:

No evidence of malignancy or lymphadenopathy
Diagnosis

Tolosa Hunt Syndrome:

Treated with Solumedrol 1000mg daily for 3 days followed by Medrol dose pack

Plan to repeat MRI in 4 weeks
Post-Discharge Follow up

Follow up in ophtho clinic:

On methylprednisone 20mg PO daily

No improvement noted per patient

No biopsy

Has neuro follow up
Tolosa Hunt Syndrome

Definition:




Episodic orbital pain associated with paralysis of one or more of the CN III, IV, VI due to
granulomatous inflammation of the cavernous sinus
Epidemiology:

One case per million per year

Same prevalence in men and women
Presentation:

Pain behind the eye followed by painful ophthalmoplegia

CN III,IV, VI palsy leading to diplopia

Unilateral 95% of time
Natural history:

Benign condition but permanent neurological deficits can occur, relapses occur in at
least 50% of patients and often requiring immunosuppressive therapy

May resolve spontaneously if left untreated
Tolosa Hunt Syndrome

Pathogenesis:



Inflammatory process of unknown etiology
Histopathology:

Nonspecific inflammation of the septa and wall of the cavernous sinus

Lymphocyte and plasma cell infiltration

Giant cell granulomas

Proliferation of fibroblasts
CN III, IV, VI and superior division of V palsy due to pressure from
inflammation
Tolosa Hunt Syndrome

Diagnostic Criteria:

95-100% sensitive, 50% specific

Unilateral HA

Granulomatous inflammation of cavernous sinus or orbit on MRI or biopsy

Paresis of CN III, IV, VI

Evidence of causation:


HA preceding oculomotor paresis

HA around ipsilateral eye
No alternative diagnosis
Imaging Findings

Axial imaging without (left) and with (right) enhancement demonstrates nonspecific fullness involving
the left cavernous sinus, consistent with Tolosa-Hunt syndrome within the context of the history.
Tolosa Hunt Syndrome


Treatment:

Glucocorticoids

Rapid resolution of pain in 24-72 hours (40%) and within 1 week (78%)

Improvement in MRI findings in 2-8 weeks
Caveat:

Lymphoma and vasculitis will also likely respond to steroids