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Abstract Details

Curious Cases of Painful Ophthalmoplegia
P1 - Poster Session 1 (8:00 AM-9:00 AM)
There were two cases of adult women (Patient G and Patient V) residing in the same neighborhood. They presented with similar complaints of right-sided orbital pain, headache, and sixth cranial nerve palsy. 
Importance of various investigations for diagnoses by exclusion and importance of starting treatment, which might be common for specific pathologies irrespective of different etiologies. (in a resource-limited environment)

On individual evaluation, Patient G had prominent right-sided dull orbital pain for 3 weeks with right-sided headache and diplopia for 1 week. Examination showed ipsilateral sixth nerve paresis. Investigations like Complete Blood Count, Complete Metabolic Panel, Chest X-ray, ANA, CSF Analysis (including Adenosine deaminase), ESR, and CRP were negative. MRI showed a single hypointense extra-axial lesion in right anteromedial temporal region, anterolateral to ipsilateral cavernous sinus. The lesion appeared to partially encase right sixth cranial nerve and approaching right superior orbital fissure. 

Patient V had similar complaints of right-sided headache for 4 weeks and diplopia for 1 week. Examination showed complete paralysis of ipsilateral sixth nerve palsy. Similarly, investigations were negative (including serum ACE levels). MRI revealed a single extra-axial hypointense lesion along right medial temporal region along with partial invasion of ipsilateral cavernous sinus. Mild asymmetric thickening of right fifth and sixth cranial nerves was seen.

Investigations were necessary to rule out differential diagnoses like tuberculous meningoencephalitis, thyroid ophthalmopathy, and other infectious, autoimmune, or neoplastic etiologies. By diagnosis of exclusion, patient G was diagnosed with Tolosa-Hunt syndrome. Though biopsy results were unavailable for patient V, she was provisionally diagnosed with Neurosarcoidosis. Both were started on Corticosteroids. On respective follow-up visits, both patients reported significant improvement in their symptoms. This further solidified the respective diagnoses in these patients.

In a resource-limited environment, response to treatment is as important as other investigations to diagnose rare diseases by exclusion.
Keshav Jayeshbhai Shah, MD (SUNY Upstate Medical University)
Mr. Shah has nothing to disclose.