Third Nerve Palsy946-6

History

A 50-year old man with type II diabetes presented with a five month history of a flu-like illness characterized by mild fevers, frequent chills, night sweats, sinus congestion, and diffused myalgias in the chest, abdomen, legs and feet. Three days prior to admission (PTA) he awoke unable to open his right eye. With his eyelid open, he saw double.

Concomitantly he experienced decreased auditory acuity, right greater than left, gait imbalance and a dull bifrontal headache. He denied photophobia, phonophobia, stiffness of the neck, vertigo, tinnitus, and ear pain. Several months PTA he had become more serious, pessimistic, and depressed. Three days PTA he became somnolent, lethargic and incoherent with impaired short-term memory and word finding.

The patient takes walks with his dog in the woods and travels frequently in the U.S. No history of drug or alcohol abuse.

ExaminationTemperature 100.3°, pulse regular, BP 150/80No neck stiffnessNo lymphadenopathy or skin rashOriented x3.Impaired short term memory, 0/3 at 3 min.Naming intact and able to readPupils: dilated, fixed 7mm OD, 2mm reactive OSEOM: complete 3rd nerve palsy OD

Fundus: normal optic discs OU8th carnial nerve, decreased hearing to a medium snap bilaterallyLimbs: mild right pronator drift and slowness of rigth dextrous movementsNo finger-to-nose or heel-to-shin ataxia. Gait ataxia and unable to tandem walkSensory exam intactReflexes 2+ bilaterally, right plantar equivocal, left flexor

Blood Tests

Rapid Plasma Reagin (RPR) test reactive at 1:64 dilutionFTA-ABS reactive 1:20ESR 68HIV antibody non reactiveSerum IgA, IgG (both elevated), IgM normal

AudiogramModerate to severe sensorineural hearing loss

Lumbar PunctureOP 180mm H20, protein 142 mg/dl, sugar 64 mg/dl

WBC 755, 27% polys, 56% lymphsIgA, IgG (both elevated), no bandingCSF VDRL reactive at 1:2 dilution, RPR reactive at 1:65

Brian MRI/DWI

Acute infarcts in the left anteromedial inferior thalamus extending into the uncus and in the left globus pallidus. No meningeal enhancement.

MRABeaded basilar artery and right PCA > left PCA

Diagnosis

Meningovascular syphilis

Therapy

Penicillin G IV 4 million units q.4h for 14 days

Vasculitis

Inflammation of blood vessels that is often accompanied by necrosis and occlusive changesClinical spectrum complexMay occur de novo as a primary disorder or as a secondary manifestation of a diverse group of systemic diseases

Vasculitis

May be generalized or localized, clinically silent or have a multitude of symptoms and serious consequences

Diagnosis depends on the correct interpretation of histological changes since there are no pathognomonic clinical and laboratory findings

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