[Binocular diplopy as the presentation of a haematoma in the rectus inferior]. / Diplopía binocular como presentación de un hematoma del recto inferior.

INTRODUCTION: The presence of quick onset binocular diplopy makes it essential to carry out a comprehensive differential diagnosis. The most frequent causes in adults include vascular, post-traumatic, tumorous and myopathic pathologies. Yet, to perform a differential diagnosis we also have to take into account less common aetiologies such as demyelinating disease, carotid-cavernous fistulas and Tolosa Hunt syndrome, among others. We report the case of a patient who was admitted to our hospital because she presented an acute onset diplopy secondary to a spontaneous haematoma of the left rectus inferior. CASE REPORT: We describe the case of a 54-year-old female with a history of hypercholesterolemia, who was a smoker and allergic to iodine contrasts and who visited because of an acute onset diplopy accompanied by instability and pain in the left eye. The neurological examination revealed paresis of the extraocular muscles dependent on the left oculomotor nerve with left palpebral ptosis, paresis of the rectus inferior, with no involvement of the pupils. Other results of the exploration were within normal limits. A computerised axial tomography scan of the head showed a haemorrhage in the rectus inferior. Magnetic resonance images of the head revealed an increase in the volume of the left-side rectus inferior with signs of bleeding, and the rest of the complementary explorations were normal. The patient progressed favourably and the diplopy gradually disappeared. CONCLUSIONS: Spontaneous bleeding of the extraocular muscles, although infrequent, must be taken into account in the differential diagnosis of painful ophthalmoplegia with diplopy in patients with no underlying pathology, especially in the absence of other neurological disorders.

Diplopía binocular como presentación de un hematoma del recto inferior / Binocular diplopy as the presentation of a haematoma in the rectus inferior

Introducción. La presencia de una diplopía binocular de instauración rápida obliga a un amplio diagnóstico diferencial. Entre las causas más frecuentes en personas adultas encontramos la patología vascular, postraumática, tumoral o miopática. Sin embargo, para realizar el diagnóstico diferencial debemos tener en cuenta etiologías menos frecuentes, como enfermedad desmielinizante, fístulas carotidocavernosas y síndrome de Tolosa-Hunt, entre otras. Presentamos el caso de un paciente que ingresó en nuestro servicio por presentar diplopía de instauración aguda secundaria a un hematoma espontáneo del recto inferior izquierdo. Caso clínico. Mujer de 54 años con antecedentes de hipercolesterolemia, fumadora y alérgica a contrastes yodados, que consulta por diplopía de instauración aguda acompañada de dolor ocular izquierdo e inestabilidad. A la exploración neurológica destaca paresia de la musculatura extraocular dependiente del III par craneal izquierdo con ptosis palpebral izquierda y paresia del recto inferior, sin afectación pupilar. El resto de la exploración estuvo dentro de la normalidad. En la tomografía axial computarizada craneal se observa una hemorragia en el recto inferior. En la resonancia magnética craneal se observó un aumento de volumen del recto inferior izquierdo con signos de sangrado, y el resto de las exploraciones complementarias fueron normales. La paciente evolucionó favorablemente y desapareció progresivamente la diplopía. Conclusión. La hemorragia espontánea de los músculos extraoculares, aunque infrecuente, debe considerarse en el diagnóstico diferencial de la oftalmoplejía dolorosa con diplopía en pacientes sin patología de base, especialmente en ausencia de otras alteraciones neurológicas (AU)

Introduction. The presence of quick onset binocular diplopy makes it essential to carry out a comprehensive differential diagnosis. The most frequent causes in adults include vascular, post-traumatic, tumorous and myopathic pathologies. Yet, to perform a differential diagnosis we also have to take into account less common aetiologies such as demyelinating disease, carotid-cavernous fistulas and Tolosa-Hunt syndrome, among others. We report the case of a patient who was admitted to our hospital because she presented an acute onset diplopy secondary to a spontaneous haematoma of the left rectus inferior. Case report. We describe the case of a 54-year-old female with a history of hypercholesterolemia, who was a smoker and allergic to iodine contrasts and who visited because of an acute onset diplopy accompanied by instability and pain in the left eye. The neurological examination revealed paresis of the extraocular muscles dependent on the left oculomotor nerve with left palpebral ptosis, paresis of the rectus inferior, with no involvement of the pupils. Other results of the exploration were within normal limits. A computerised axial tomography scan of the head showed a haemorrhage in the rectus inferior. Magnetic resonance images of the head revealed an increase in the volume of the left-side rectus inferior with signs of bleeding, and the rest of the complementary explorations were normal. The patient progressed favourably and the diplopy gradually disappeared. Conclusions. Spontaneous bleeding of the extraocular muscles, although infrequent, must be taken into account in the differential diagnosis of painful ophthalmoplegia with diplopy in patients with no underlying pathology, especially in the absence of other neurological disorders (AU)

[Peripheral and optical myeloneuropathy in a folic acid deficient alcoholic patient]. / Mieloneuropatía periférica y óptica en un paciente alcohólico deficiente en ácido fólico.

INTRODUCTION: In Western countries, neurological disorders secondary to toxic nutritional problems usually present as isolated cases that are generally associated to identifiable causes (alcoholism, eating disorders, absorption disorders, use of medicines) that reduce the availability of basic nutrients, especially B group vitamins, but also folic acid (FA). The optic nerves and the peripheral axons are frequent target organs in this type of pathology, but leukoencephalopathy and spinal cord involvement may also appear, often in combination. CASE REPORT: We describe the case of a 38-year-old female smoker with a heavy alcohol habit, who developed a subacute clinical pattern of, predominantly axonal, sensitive peripheral polyneuropathy, with vegetative fibre involvement. She also presented involvement of the posterior spinal cord, which gave rise to an ataxic disorder in the gait, as well as a severe bilateral retrobulbar optic neuropathy. Likewise, she presented macrocytosis (MCV: 118) due to megaloblastosis. She was also found to have a FA deficit but a normal vitamin B12 metabolism. With the help of supplementary vitamins, stopping drinking and the regularisation of her diet, the patient presented progressive clinical improvement, and was able to walk without support at 3 months and almost completely recovered her sight, which was corroborated by an improvement in the studies of both visual and somatosensorial evoked potentials. CONCLUSIONS: In our community, alcoholism is a frequent cause of nutritional deficiencies, which lead to neurological problems. FA is one of the nutrients that become deficient in alcoholics. More and more descriptions are being reported of peripheral polyneuropathy, retrobulbular optic neuropathy, myelopathy or leukoencephalopathy associated to FA deficiency, above all in patients with a history of alcoholism.

Mieloneuropatía periférica y óptica en un paciente alcohólico deficiente en ácido fólico / Peripheral and optical myeloneuropathy in a folic acid deficient alcoholic patient

Introducción. En los países occidentales, los trastornos neurológicos secundarios a problemas toxiconutricionales suelen presentarse como casos aislados, generalmente asociados a causas identificables (alcoholismo, aberraciones dietéticas, trastornos de la absorción, uso de fármacos), que disminuyen la disponibilidad de algunos nutrientes básicos, fundamentalmente vitaminas del grupo B, pero también de ácido fólico (AF). Los nervios ópticos y los axones periféricos son dianas frecuentes en este tipo de patologías, pero también pueden aparecer, frecuentemente en combinación, leucoencefalopatía y afectación medular. Caso clínico. Mujer de 38 años, fumadora y con hábito alcohólico importante, que desarrolló un cuadro subagudo de polineuropatía periférica, sensitiva, con afectación de las fibras vegetativas, y de predominio axonal, junto a afectación cordonal posterior, que provocó trastorno atáxico de la marcha, así como neuropatía óptica retrobulbar bilateral grave. Igualmente presentaba macrocitosis (VCM: 118) debida a megaloblastosis. Se halló deficiencia de AF con un metabolismo de la vitamina B12 normal. Con suplementos vitamínicos, el abandono del hábito alcohólico y la normalización de la dieta, la paciente presentó una mejoría clínica progresiva, y fue capaz de deambular sin apoyo a los tres meses, con una recuperación casi completa de la función visual, todo ello corroborado por una mejoría en los resultados de los estudios de potenciales evocados, tanto visuales como somatosensoriales. Conclusiones. En nuestro medio, el alcoholismo es una causa frecuente de deficiencias nutricionales, que ocasionan problemas neurológicos. El AF es uno de los nutrientes que se hace deficitario en el alcoholismo. Cada vez aparecen más descripciones de polineuropatía periférica, neuropatía óptica retrobulbar, mielopatía o leucoencefalopatía asociadas a una deficiencia de AF, sobre todo en pacientes con abuso de alcohol (AU)

Introduction. In Western countries, neurological disorders secondary to toxic-nutritional problems usually present as isolated cases that are generally associated to identifiable causes (alcoholism, eating disorders, absorption disorders, use of medicines) that reduce the availability of basic nutrients, especially B group vitamins, but also folic acid (FA). The optic nerves and the peripheral axons are frequent target organs in this type of pathology, but leukoencephalopathy and spinal cord involvement may also appear, often in combination. Case report. We describe the case of a 38-year-old female smoker with a heavy alcohol habit, who developed a subacute clinical pattern of, predominantly axonal, sensitive peripheral polyneuropathy, with vegetative fibre involvement. She also presented involvement of the posterior spinal cord, which gave rise to an ataxic disorder in the gait, as well as a severe bilateral retrobulbar optic neuropathy. Likewise, she presented macrocytosis (MCV: 118) due to megaloblastosis. She was also found to have a FA deficit but a normal vitamin B12 metabolism. With the help of supplementary vitamins, stopping drinking and the regularisation of her diet, the patient presented progressive clinical improvement, and was able to walk without support at 3 months and almost completely recovered her sight, which was corroborated by an improvement in the studies of both visual and somatosensorial evoked potentials. Conclusions. In our community, alcoholism is a frequent cause of nutritional deficiencies, which lead to neurological problems. FA is one of the nutrients that become deficient in alcoholics. More and more descriptions are being reported of peripheral polyneuropathy, retrobulbular optic neuropathy, myelopathy or leukoencephalopathy associated to FA deficiency, above all in patients with a history of alcoholism (AU)