Internuclear ophthalmoplegia as a presenting feature in a COVID-19-positive patient.

A 58-year-old man presented with vertical diplopia for 10 days which was sudden in onset. Extraocular movement examination revealed findings suggestive of internuclear ophthalmoplegia. Investigations were suggestive of diabetes mellitus, and reverse transcription-PCR for SARS-CoV-2 was positive. At 3 weeks of follow-up, his diplopia had resolved. Neuro-ophthalmic manifestations in COVID-19 are increasingly being recognised around the world. Ophthalmoplegia due to cranial nerve palsy and cerebrovascular accident in COVID-19 has been reported. We report a case of internuclear ophthalmoplegia in a patient with COVID-19.

Concurrent tonic pupil and trochlear nerve palsy in COVID-19.

Since COVID-19 was first reported, different neurological complications have been acknowledged, but their description is constantly evolving. We report a case of concurrent tonic pupil and trochlear nerve palsy in this context. A 62-year-old man reported a 5-day history of binocular vertical diplopia and blurred vision in his left eye, noticing that his left pupil was dilated. He had suffered a flu-like syndrome 2 weeks before. Clinical exam showed a right trochlear nerve palsy and a left mydriatic pupil. MRI, X chest ray, and analytical results were normal. Antibodies for SARS-CoV-2 were positive (low IgM and high IgG titers). Antiganglioside antibodies were negative. A 0.125% pilocarpine test confirmed Adie's pupil diagnosis. The patient was treated with a tapered prednisone dose with resolution of his diplopia but no change in Adie's pupil. This is the first case reporting Adie's pupil as a postinfectious manifestation of COVID-19. An immune-mediated mechanism is presumed.

Infección por SARS-CoV-2 asociada a diplopía y anticuerpos antirreceptor de acetilcolina / SARS-CoV-2 infection associated with diplopia and anti-acetylcholine receptor antibodies

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Herpes simplex virus type 2 meningitis as a manifestation of Good's syndrome.

Good's syndrome is a primary immunodeficiency phenocopy characterized for thymoma and immunodeficiency. The most frequent clinical presentation is recurrent or opportunistic infections, hematological alterations, and chronic diarrhea. We treated a 66-year-old man who consulted for 5 days of headache and diplopia with right sixth cranial nerve palsy at examination. Patient reported chronic diarrhea and prolonged febrile syndrome accompanied by weight loss of 23 kg in the last year. Exhaustive evaluation revealed Herpes simplex virus (HSV) type 2 meningitis, eosinophilic colitis, and type A thymoma. Severe antibody deficiency (hypogammaglobulinemia) associated with thymoma confirmed the diagnosis of Good's syndrome.

Miller Fisher syndrome developing as a parainfectious manifestation of dengue fever: a case report and review of the literature.

BACKGROUND: Although dengue viral infections have emerged as one of the most important mosquito-borne diseases, neurological manifestations of dengue infections are uncommon. Guillain-Barré syndrome and Miller Fisher syndrome have been reported to occur as immune-mediated complications following dengue infection. We report the case of a patient who developed Miller Fisher syndrome during the acute phase of dengue fever suggesting that Miller Fisher syndrome may arise as a result of direct neurotropism of the dengue virus. CASE PRESENTATION: A 70-year-old Sri Lankan man with well-controlled diabetes mellitus and hypertension presented with fever of 3 days' duration, drooping of eyelids, dysarthria, and unsteady gait. He developed bilateral asymmetric partial ptosis, complete external ophthalmoplegia, bilateral palatal palsy, unilateral tongue weakness, ataxia, and areflexia from the second day of illness. He did not have limb weakness. He had evidence of acute dengue infection including progressive thrombocytopenia and leukopenia, positive dengue non-structural protein 1 antigen, dengue immunoglobulin M antibodies, and polymerase chain reaction detection of dengue virus genome in serum. Magnetic resonance imaging of his brain and cerebrospinal fluid analysis were normal. Polymerase chain reaction for dengue virus and immunoglobulin M antibodies in cerebrospinal fluid were negative. Nerve conduction studies showed axonal neuropathy. Antibodies (immunoglobulin G, immunoglobulin M, and immunoglobulin A) against GQ1b and GT1a were negative. He was treated with intravenously administered immunoglobulins and a recommended fluid regimen for dengue fever. He made a complete recovery from dengue fever in 7 days and Miller Fisher syndrome in 20 days. CONCLUSIONS: This case report highlights the rare occurrence of Miller Fisher syndrome during the acute phase of dengue fever. Neurological manifestations may occur as a consequence of direct neurotropism of dengue virus.

Acute enteroviral meningoencephalitis as unusual cause of diplopia in pregnancy and puerperium.

OBJECTIVE: To describe unusual cause of diplopia in early puerperal period. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology, 2nd Faculty of Medicine and Faculty Hospital Motol. CASE REPORT: 34-year-old patient at 39 weeks of gestation complaining fever, headache and blurring of vision was referred to our medical center. She underwent caesarean section for tachycardia of fetus. Symptoms remained during early puerperium. We describe diagnostic and treatment hesitations. CONCLUSION: The cause of her complains was viral meningoencephalitis which led in postencephalitic syndrome.

Diplopia as isolated presentation of varicella zoster central nervous system reactivation.

Here, we report a patient who developed diplopia secondary to a right cranial nerve III and IV palsy, as well as fever and headache. Cerebrospinal fluid analysis (CSF) showed high varicella-zoster virus (VZV)-DNA viral load (>300,000,000 copies/ml). VZV antibodies in CSF was ≥1:16. Diagnosis of neurological reactivation of VZV infection was made without the presence of characteristic vesicular rash. Quantitative real-time PCR for VZV and intrathecal dosage of VZV IgM and IgG should be performed in cases suspected for viral encephalitis and also in all patients with not otherwise attributable cranial nerve lesions.

Progressive multifocal leukoencephalopathy in a patient without apparent immunosuppression.

Progressive multifocal leukoencephalopathy (PML) is a viral demyelinating disease due to the reactivation of the JC virus (JCV), which usually occurs in the context of immunosuppression in HIV infection, malignancy, or in patients on disease modifying therapy for autoimmune diseases, such as multiple sclerosis (MS) and Crohn's disease. Notably, there is growing recognition that PML can occur in patients with transient immune dysfunction. Here, we present a case of a 55-year-old man without history of immunosuppression or evidence of ICL who was diagnosed with PML on brain biopsy. We will discuss the potential etiologies of mild and transient immunosuppression that can lead to PML with non-apparent immunosuppression.

Unique presentation of 3rd and 6th cranial nerve palsies, nodular scleritis and nummular keratouveitis in an immunocompetent patient following an attack of herpes zoster ophthalmicus.

AIM: To report a unique presentation of 3rd and 6th cranial nerve palsies with nodular scleritis and nummular keratouveitis following an attack of herpes zoster ophthalmicus (HZO). METHODS: Case report. CASE REPORT AND RESULTS: A 56-year-old woman with a 1-month history of HZO presented with drooping of the right upper eyelid, diplopia, and pain around the right eye. She was noted to have right 3rd and 6th cranial nerve palsies. She developed nodular scleritis and nummular keratouveitis at 2 and 4 months follow-up, respectively, which were treated with antivirals and steroids. At 10 months follow-up, although the diplopia in right lateral gaze persisted, there was no recurrence of ocular inflammation with complete recovery of ptosis. CONCLUSIONS: A unique presentation of multiple cranial nerve palsies with nodular scleritis and nummular keratouveitis in an immunocompetent patient following an attack of HZO is highlighted in this report.

[Benign but not harmless intracranial hypertension: a case report]. / Hypertension intracrânienne bénigne, mais pas anodine. À propos d'un cas.

Benign intracranial hypertension (BIH) is characterized as an intracranial pressure increase occurring in the absence of brain tumour, sinus thrombosis or hydrocephaly. But contrary to what its designation might suggest, it threatens the visual prognosis. We report the case of a 15-year-old girl with lymphocytic meningitis, developing secondary a BIH. Cerebrospinal fluid pressure was 70cm water, without enlargement of the cerebral ventricles. Along with the progression, bilateral 6th nerve palsy, impairment of visual acuity and bilateral papilledema appeared. No cause was found after a complete assessment. Treatment consisted in oral acetazolamide and 9 depletive spinal taps. Clinical examination, fundus examination and Goldmann visual field normalized after 8 weeks. No relapse occurred after a 1-year follow-up. This case shows that BIH, which is not a well-known disorder, is incorrectly referred to as benign: both prompt diagnosis and proper management are of major importance.

Rabies in humans.

This column discusses the etiology and clinical manifestation of and postexposure prophylaxis for rabies in humans.

Temporary divergence paralysis in viral meningitis.

A 43-year-old woman who reported diplopia and headache was found to have comitant esotropia at distance fixation and normal alignment at reading distance (divergence paralysis). Eye movement, including abduction, was normal as was the rest of the neurologic examination. Brain MRI was normal. Lumbar puncture showed an elevated opening pressure and a cerebrospinal fluid formula consistent with viral meningitis. The patient was treated with intravenous fluids and analgesics and with a temporary prism to alleviate diplopia. Within 3 weeks, she had fully recovered. This is the first report of divergence palsy in viral meningitis.

Diplopia: a focal neurologic presentation of West Nile meningoencephalitis.

This is a report of a 45-year-old white man who presented to our emergency department with a 2-day history of "seeing double" preceded by a resolving 5-day syndrome of fevers and headache. Clinical suspicion of West Nile virus central nervous system infection was confirmed on the basis of laboratory studies. The current knowledge of West Nile virus pathophysiology and clinical features are discussed. Although commonly associated with global and nonspecific syndromes, this patient presented with focal neurologic symptoms.