Authors : Harsh Nawal
DOI : 10.1212/01.wnl.0001050852.00972.4c
Volume : 103
Issue : 1
Year : 2024
Page No : S1
Presentation - A 41 year-old female presented with low-grade fever, unilateral right-sided headache, drooping of right upper eyelid and double vision for the past 7 days. Clinical Findings - Upon examination, right-sided recti muscles showed complete weakness with restriction of oblique muscles. Diplopia was present on looking rightwards, upwards and at distance. Right-sided pupillary reflex was sluggishly reactive. On the contrary, movements, pupil and eyelid of left side were normal. All other general, systemic and neurological examinations were normal. In conclusion, this was a case of Right-sided CN III, IV, VI involvement without other long-tract signs. Thus, isolated cavernous sinus syndrome was considered. Approach - Considering the acute onset, either inflammatory or SOL etiology was suspected. Laboratory and radiological tests were ordered. HbsAg, anti-HCV, ICTC were non-reactive. Mantoux Test was positive. Serum ACE was elevated (86 IU/L). CSF showed elevated cell count (mostly mononuclear) but CBNAAT and ZN-smear were negative. ANA, ANCA negative. MRI brain-orbit showed enhancing lesions in the right parasellar region involving the cavernous sinus and right parapharyngeal regions, with inflammation and developing abscess. Biopsy could not be done. CT-thorax showed bilateral superior mediastinal lymphadenopathy and collection over left sternoclavicular joint. Lymph node biopsy shows non-caseating epithelioid granuloma with Langhans giant-cells. Diagnosis - Case of right-sided cavernous sinus syndrome associated with superior mediastinal lymphadenopathy and features of dissemination in an immunocompetent patient with histopathological diagnosis of tuberculosis. Treatment and Followup - Patient was treated with empirical ATT and steroid therapy. Dramatic improvement in symptoms was seen after a 2 week followup. Case Uniqueness - Coexistence of features of immuno-competence (non-caseating granulomas) and immuno-incompetence (disseminations) makes the case unique. While granulomatous satellite lesions (disseminations) and abscesses (infective) indicate tuberculosis, presence of non-caseating granulomas, superior mediastinal lymphadenopathy with elevated ACE indicate sarcoidosis. Thus, we consider the possibility of the entity tuberculous-sarcoidosis