Diplopia, Orbital Pain, and Vision Loss in a Middle-Aged Woman

A 59-year-old woman with type 2 diabetes had development of fluctuating, binocular, painless diplopia. She experienced headache, orbital pain, facial numbness, and progressive vision loss in the left eye. Her left eye vision worsened. Magnetic resonance imaging of the brain and orbit showed bilateral optic nerve enhancement. She started treatment with empiric intravenous corticosteroids for presumed optic neuritis, which resulted in transient improvement. Subsequently, her vision worsened to no light perception in the left eye, and she had fluctuating vision loss in the right eye. Cerebrospinal fluid evaluation was performed because the patient’s fluctuating diplopia and facial numbness suggested involvement of multiple cranial nerves. The cerebrospinal fluid showed white blood cells with lymphocytes, increased protein concentration, and negative oligoclonal bands and cytologic findings. Repeated brain magnetic resonance imaging 1 year after symptom onset showed persistent bilateral (left > right) optic nerve enhancement along with oculomotor nerve and left midbrain enhancement. We recommended left optic nerve biopsy to obtain the diagnosis and attempt to preserve vision in the threatened right eye. Because the patient had no light perception in the left eye for 5 months, with significant pallor of the optic nerve, it was unlikely that she had salvageable left eye vision. Furthermore, there was concern for lymphomatous infiltration of the optic nerve. Confirmation of a lymphoma diagnosis would be critical for initiation of specific chemotherapy. The pathologic analysis identified noncaseating granulomas. The finding of noncaseating granulomas was consistent with neurosarcoidosis infiltrating the left optic nerve. The patient was treated with intravenous methylprednisolone followed by prolonged, high-dose, oral corticosteroids along with corticosteroid prophylaxis of calcium, vitamin D, a proton-pump inhibitor, and dapsone for Pneumocystis prophylaxis Sarcoidosis is a systemic disease of unknown cause that can occur anywhere in the body but most commonly involves the lungs. The pathologic hallmark of sarcoidosis is noncaseating granulomas.

A RETROSPECTIVE STUDY OF RHINO-ORBITAL MUCORMYCOSIS

BACKGROUND: Mucormycosis is a rapidly progressing, life threatening, opportunistic fungal infection caused by angioinvasive mucorales species of the phylum zygomycetes.The major risk factors of the disease are uncontrolled diabetes mellitus, COVID-19 infection,prolonged usage of high dose of systemic corticosteroids,immunocompromised status and neutropenia. These create a nidus for fungal infection through nasal mucosa which spreads up through paranasal sinuses into orbit manifesting as rhino-orbital mucormycosis. AIM 1. To study the epidemiology and various clinical patterns of presentation of rhino-orbital mucormycosis in post covid patients. 2. To analyse the risk factors associated with progression of rhino-orbital mucormycosis in post covid patients. METHODS: A retrospective study of 25 patients diagnosed as rhino-orbital mucormycosis in post covid patients at Government Kilpauk Medical College Hospital between April and July 2021 was done. RESULTS: In our study,males (64%) are more commonly affected with age preponderance of 51-60 years(28%). The mean age of presentation was 52.1+/-4.49years.The most common symptom of the disease is nasal discharge with sinus and orbital pain(52%).The most common form of presentation is orbital apex syndrome in seven patients(28%).Five patients had loss of vision, of which four were due to central retinal artery occlusion(16%) and one due to cavernous sinus thrombosis.MRI imaging of these patients showed sinus involvement(100%) in all cases ,orbital(48%) and cerebral involvement(8%).The major risk factors responsible for progression of disease in our study are uncontrolled diabetes, prolonged usage of high dose steroid therapy, medial wall involvement, optic nerve head involvement and artery thrombosis. CONCLUSION: Post covid patients presenting with nasal discharge with sinus and orbital pain symptoms need to be diagnosed and managed properly to avoid spread of infection and fatal complications. Aggressive surgical debridement of infected tissues helps in increasing the survival rate of the patients. Patients with risk factors need to be closely monitored to prevent vision loss and cosmetic disfigurement surgeries.

Diagnosis of dengue fever in a patient with early pregnancy loss

Dengue is a mosquito-borne virus that causes an influenza-like illness ranging in severity from asymptomatic to fatal. Dengue in pregnancy has been associated with adverse outcomes including miscarriage, preterm birth and fetal and neonatal death. We present the case of a multiparous woman who presented at 9 weeks’ gestation with vaginal bleeding and abdominal cramping after a 1 month stay in Mexico. She was initially diagnosed with miscarriage with plan for outpatient follow-up. She was readmitted 3 days later with fever, retro-orbital pain, arthralgia, rash, pancytopenia and transaminitis and managed with intravenous fluids and acetaminophen. Of note, dengue serology was initially negative but retesting 2 days later was positive. It is imperative that clinicians have heightened suspicion for dengue in pregnant women with history of travel to or residence in a dengue-endemic area and consistent clinical evidence.

Pituitary Apoplexy Complicated by Cerebral Infarction: A Case Report

Cerebral infarction is a rare complication of pituitary apoplexy, which can result in significant morbidity if not treated on time. Pituitary apoplexy mostly occurs in pre-existing adenoma, which can remain undiagnosed until symptoms arise. Here, we present a case of a 26-year-old man with undiagnosed acromegaly who presented with left retro-orbital pain, diminished vision of the left eye, and right hemiparesis. Neuroimaging revealed large hemorrhagic sellar mass and ischemic infarction in the left middle cerebral artery territory. Emergency transcranial tumor excision was done, which resulted in significant neurological recovery.

Asymptomatic COVID 19 infection: An innocent bystander in Mucormycosis or maybe not?

We report a case of 48 year old male with past medical history of poorly controlled Diabetes mellitus, Chronic Liver Disease-child Pugh B who came with complaints of left frontal headache and left orbital pain. A clinical diagnosis of possible Rhinorbital Mucormycosis was made and further confirmed by potassium hydroxide (KOH) mount from tissue, which showed broad sparsely septate hyphae and fungal culture grew Rhizopus oryzae. Covid 19 infection was detected as an incidental finding on admission to the hospital. The patient was successfully treated with surgical debridement and liposomal Amphotericin B followed by oral Posaconazole.

Optic perineuritis in polyarthritis nodosa

A 52-year-old male patient with polyarthritis nodosa (PAN) was referred to our neurology outpatient clinic. His main symptom was paroxysmal alternating bilateral blindness. Subsequently, he developed retro-orbital pain. Neurological examination including funduscopy was normal and laboratory tests showed no relevant abnormalities. MRI orbits showed remarkable perineural thickening and contrast enhancement of the optic nerve sheaths with sparing of the central optic nerve. These findings are pathognomonic for the clinical-radiological diagnosis of optic perineuritis (OPN). The patient was treated with high-dose immunosuppressants and had a good clinical outcome. Rapid diagnosis of OPN is important because early treatment is associated with a better outcome.

Facial Neuritis as a Manifestation of Gradenigo's Syndrome

Gradenigo's syndrome (GS) is a rare, acquired syndrome caused by middle ear infections or mastoiditis. It is identified by the triad of otorrhea due to otitis media (OM), retro-orbital pain in the region innervated by the first and second divisions of the trigeminal nerve, and diplopia as a result of cranial nerve (CN) VI palsy. As a result of extension of the inflammation, the facial nerve (VII) may also be affected. GS has a poor prognosis unless promptly diagnosed and treated. Herein, we report the clinical and radiological findings observed in two children diagnosed with chronic suppurative OM, mastoiditis, and facial neuritis. Both were medically managed as cases of GS with high-dose intravenous antibiotic and full recovery was achieved a few weeks after discharge. There was no need for any surgical intervention. This report illustrates the importance of early recognition, diagnosis, and treatment of this treatable syndrome using antibiotics to prevent subsequent fatal complications and further need for surgical intervention.

Missed Diagnosis of Subarachnoid Haemorrhage

A 79-year-old woman presented with left retro-orbital pain, headache and blurred vision. Based on negative radiological tests, life-threatening conditions like subarachnoid haemorrhage (SAH) were ruled out and outpatient follow-up was planned. However, the patient returned to the hospital that night because of progressively declining consciousness and was diagnosed with SAH by head computed tomography. The diagnosis of SAH is often challenging, especially in cases with negative radiological results. We describe some strategies, other than radiological examination, for ruling out SAH, such as performing a lumbar puncture and repeating tests to take account of disease progression, and describe biases which can affect clinical decision-making.

Hypertrophic pachymeningitis and orbital tumor associated with Granulomatosis with polyangiitis: report of a clinical case

A 65-year-old patient, with a diagnosis of Granulomatosis with Polyangeitis (GPA) of 18 years of evolution, whose debut was with respiratory failure and hemoptysis, receiving induction treatment with corticosteroids together with cyclophosphamide, and then maintenance treatment with azathioprine 150 mg per day, with periods of flare-up of the disease that responded to treatment with corticosteroids for short periods. He came to the clinic for a 3-month-long chronic headache refractory to treatment with non-steroidal anti-inflammatory drugs (NSAIDs), associated with left ocular proptosis and ipsilateral orbital pain. presenting elevated acute phase reactants (ers and c-reactive protein). It is evidenced by brain magnetic resonance with gadolinium, enhancement of the cerebral dura and cerebellum store, also presenting formation in the left orbit.