Aseptic meningitis after amenamevir treatment for herpes zoster ophthalmicus with oculomotor nerve palsy in a patient taking immunosuppressant.

A 79-year-old woman presented with vomiting after being prescribed amenamevir by her primary care physician. She had a medical history of rheumatoid arthritis and was administered prednisolone and methotrexate. She was finally diagnosed with herpes zoster ophthalmicus and aseptic meningitis, and intravenous antiviral therapy was initiated. However, the patient developed oculomotor nerve palsy on the 11th day of hospitalization. In this case, there was a time lag between the administration of antiviral drugs and clinical improvement. Our case suggests the necessity of selecting antivirals, especially in high-risk cases of CNS complications, to avoid the low intracerebral transferability of antiviral drugs, including amenamevir.

Diabetic Oculomotor Nerve Palsy Displaying Enhancement of the Oculomotor Nerve in the Orbit and Cavernous Sinus on MRI.

INTRODUCTION: Imaging data were scarce on diabetic oculomotor nerve palsy (ONP). Our study explored the MRI features and their clinical implications for diabetic ONP. METHODS: Fifty-nine patients with a clinical diagnosis of diabetic ONP were recruited from our department between January 2015 and December 2019. Orbital MRI was retrospectively analyzed, and follow-up scans were obtained for 5 patients. Based on the ocular motor nerve palsy scale, the difference in the scores on the first and last hospital days was defined as the improvement score and was used to assess the treatment effects in all. RESULTS: Thirty-eight (64.41%) patients presented thickening and enhancement of the cavernous segment and inferior division of the intraorbital segment of the ipsilateral oculomotor nerve, with the cisternal segment spared in all. After complete resolution of symptoms, follow-up MRI in 5 patients revealed that the enhancement was less obvious compared with the previous images. 6 patients in the enhancement group and 4 patients in the nonenhancement group were treated with 80 mg of methylprednisolone. Significant differences were not detected in the median improvement scores between patients with and those without corticosteroid use (p = 0.240). CONCLUSION: Thickening and enhancement of the unilateral oculomotor nerve were common imaging findings in diabetic ONP, and they persisted after complete resolution of symptoms in some patients. The cavernous segment and the inferior division of the intraorbital segment were simultaneously involved, and the cisternal segment was often spared. Refraining from corticosteroids was recommended even with nerve enhancement.

Anti-IgLON5 disease with distinctive brain MRI findings responding to immunotherapy: A case report.

RATIONALE: Anti-IgLON5 disease was first described as a progressive antibody-associated encephalopathy, with multiple non-specific clinical symptoms including sleep dysfunction, bulbar symptoms, progressive supranuclear palsy-like syndrome, cognitive impairment, and a variety of movement disorders. This newly discovered disease presents with unremarkable or unspecific brain magnetic resonance imagings (MRI), and have poor responsiveness to immunotherapy. PATIENT CONCERNS: In this case, a 37-year-old man presented with 4-day history of gait instability, dysarthria, and oculomotor abnormalities. The initial neurologic examination revealed mild unsteady gait, subtle dysarthria, and left abducent paralysis. DIAGNOSIS: The patient was diagnosed with anti-IgLON5 disease, based on clinical features and positive anti-IgLON5 antibodies in serum. INTERVENTIONS: Initially, the patient was treated with high dosages of methylprednisolone and immunoglobulins.Outcomes: The symptoms of patient rapidly improved after high-dose intravenous methylprednisolone and immunoglobulins. CONCLUSIONS: In this paper, we report a new case of anti-IgLON5 disease with major symptoms of gait instability, dysarthria, and oculomotor abnormalities, with distinctive brain MRI findings, and responsive to immunotherapy.

[A case of advanced pancreatic cancer with oculomotor nerve palsy caused by herpes zoster after introduction of gemcitabine plus nab-paclitaxel].

A 76-year-old woman was admitted to our hospital due to diabetes and was diagnosed with advanced pancreatic cancer for which she received gemcitabine plus nab-paclitaxel. Fourteen days later, eruptions were observed in the first division of the right trigeminal nerve;she was then diagnosed with herpes zoster and was successfully treated with antiviral therapy. Seven days after the herpes zoster infection, right ophthalmoplegia appeared. Oculomotor nerve palsy secondary to herpes zoster ophthalmicus was suspected and she was treated with steroid pulse therapy. Her symptoms improved, and chemotherapy was able to be continued. Her ophthalmoplegia had almost fully resolved 41 days after the onset of herpes zoster infection.

Disseminated lymphoblastic lymphoma revealed by an isolated third cranial nerve palsy.

Dysfunction of the third cranial nerve can be provoked by a number of different conditions. An isolated cranial neuropathy as a first clinical sign of a non-Hodgkin lymphoma is very infrequent. We represent here an atypical case of lymphoblastic lymphoma revealed by an isolated third cranial nerve palsy. The patient was managed by alternating cycles of cyclophosphamide, vincristine, and prednisone. She made a full recovery with a complete resolution of the symptomatology.

Parálisis oculomotoras en el contexto de una reactivación del virus varicela-zóster: a propósito de 4 casos / Oculomotor nerve palsy in herpes zoster ophthalmicus: Presentation of 4 cases

La infección por el virus varicela-zóster (VVZ) tiene una alta prevalencia a nivel mundial. De las muchas manifestaciones oftalmológicas que puede manifestar, la diplopía de aparición brusca es una de ellas. Revisamos 4 casos clínicos de mononeuritis del III y VI par craneales en el contexto de vesículas herpéticas por el VVZ y revisamos la fisiopatología y las manifestaciones clínicas más importantes. Es obligado para el oftalmólogo descartar complicaciones mediante pruebas de imagen y el correcto tratamiento con antivirales sistémicos

Varicella zoster virus (VZV) infection has a high prevalence worldwide. Within the multiple ophthalmologic manifestations that VZV can cause, sudden diplopia is among them. A review is presented of four clinical cases of 3rd and 4th oculomotor nerve palsies in herpes zoster ophthalmicus. A review is also presented of the physiopathology and most important clinical manifestations. Imaging tests are essential in order to rule out complications. Systemic antiviral administration is the correct treatment

The oculomotor neurovascular conflict: Literature review and proposal of management.

BACKGROUND: The Oculomotor nerve (OCN) lies in a close relationship with large arteries inside the basal cisterns. Therefore, it may be compressed by vascular malformations or aneurysms. Nevertheless, the compression is not always related to pathologic conditions. Indeed, some cases of neurovascular conflicts of the OCN have been described in the literature. METHODS: A case of neurovascular conflict of the OCN resolved after steroid treatment is reported. Additionally, a systematic literature review of those cases was performed. RESULTS: OCN palsy due to a neurovascular conflict has been described as acute or chronic persistent palsy, or with an intermittent presentation. Symptoms result from compression, although asymptomatic compression is not uncommon. Surgical treatment, pharmacological treatment, and observation have been reported as options in the literature. Microvascular decompression was employed effectively in some cases of OCN neurovascular conflict. Nevertheless, other cases were treated successfully with steroids (persistent presentation) and carbamazepine (intermittent presentation). A management algorithm based on the results of the literature review is proposed. CONCLUSIONS: Treatment options for OCN neurovascular conflicts and their results are heterogeneous. Based on the literature review, the pharmacological treatment seems to be the most appropriate first-line approach, reserving surgery for refractory cases. Collecting clinical information about new cases will allow defining treatment standards for this rare condition.

Case Report: Varicella-zoster Encephalitis with Acute Retinal Necrosis and Oculomotor Nerve Palsy.

SIGNIFICANCE: Varicella-zoster virus is a common cause of morbidity and vision loss in patients worldwide. It can affect any structure of the eye, from keratitis to acute retinal necrosis. Rapid diagnosis and treatment significantly improve clinical outcomes and quality of life. PURPOSE: The purpose of this study was to demonstrate a case where urgent referral to the emergency department was required to treat a patient with disseminated herpes zoster infection. CASE REPORT: This is a rare case of varicella-zoster virus encephalitis in a 70-year-old immunocompetent white man who initially presented to the eye clinic for vertical diplopia and floaters. He also had prior thoracic dermatomal rash, followed by new-onset headaches and cerebellar ataxia. Examination revealed a partial oculomotor nerve palsy in the right eye with bilateral optic disc edema and areas of retinitis consistent with acute retinal necrosis in both eyes. Polymerase chain reaction analysis of his aqueous humor and cerebrospinal fluid confirmed an active zoster infection. He received combination systemic and intravitreal antiviral medication until his retinitis resolved but required adjustments for recalcitrant disease and drug-induced nephrotoxicity. While on maintenance dosing of oral valacyclovir, he experienced reactivation in the form of bilateral vasculitis, which was successfully managed once restarting therapeutic oral dosing. CONCLUSIONS: This case describes a successful clinical course of acute retinal necrosis with strategies for its treatment in the setting of varicella-zoster encephalitis. Antiviral medication should be given as soon as possible, as prompt treatment has been shown to improve patient outcomes, although prognosis is typically poor in these cases. Multiple specialists are often needed to address different clinical challenges, including central nervous system involvement, viral strain resistance, disease reactivation, and drug toxicity.

Monocular Oculomotor Nerve Disorder Manifesting as Cranial Neuropathy in Systemic Lupus Erythematosus.

We herein report the case of a patient who developed peripheral neuropathy of the bilateral lower legs that later became complicated with isolated oculomotor nerve disorder and was finally diagnosed as systemic lupus erythematosus (SLE). Based on the findings for oculomotor nerve paralysis and contrast-enhanced magnetic resonance imaging findings for the oculomotor nerve in the prepontine cistern, the isolated oculomotor nerve disorder was considered to be a manifestation of peripheral neuropathy. This oculomotor nerve disorder may contribute to the diagnosis of SLE and can be effectively treated with steroid pulse therapy. Reports of SLE manifesting as isolated oculomotor nerve paralysis are rare.

Unique case of midbrain tuberculoma presenting as isolated inferior rectus palsy with nystagmus.

Isolated brain stem tuberculoma constitutes about 5% of all intracranial tuberculomas. A case of isolated inferior rectus palsy with downbeat nystagmus due to presumed midbrain tuberculoma in an immunocompetent patient is described here. This report documents a rare entity of a combination of partial third nerve palsy with pupil involvement along with downbeat nystagmus.

Third Cranial Nerve Palsy after a Chikungunya Virus Infection.

Chikungunya fever is a disease caused by a virus from the same family as dengue and Zika. It is endemic in several parts of the world and has recently spread to Latin America. We report the case of a patient, aged 58 years, from Rio de Janeiro, Brazil, who in 2013 developed an acute bilateral third cranial nerve palsy sparing the pupil. After extensive investigation, it was diagnosed as caused by chikungunya infection. The patient was treated with pulse therapy and after 5 months of the onset of the condition, the patient showed improvement.

Isolated Third Cranial Nerve Palsy Leading to the Diagnosis of Disseminated Burkitt Lymphoma: A Case Report and Literature Review.

INTRODUCTION: Dysfunction of the third cranial nerve can result from lesions anywhere along its course between the midbrain and the orbit. Lymphoma is a rare cause of isolated oculomotor nerve palsy (OMP), with only 19 cases reported in the literature. We describe a case of an isolated OMP leading to the diagnosis of disseminated Burkitt lymphoma (BL). CASE REPORT: A 37-year-old man presented with acute onset diplopia and right ptosis and was found to have a right pupillary sparing OMP. The diagnostic workout was unremarkable, including contrast-enhanced brain and orbital magnetic resonance imaging, MR angiography, exhaustive laboratory tests, and cerebrospinal fluid analysis. After a course of high-dose intravenous steroid therapy, the patient recovered almost completely. Three weeks after the discharge, he developed lumbar radicular pain and lower limbs weakness followed by the relapse of the right OMP. A second lumbar puncture revealed the presence of "small monomorphic lymphocytes," consistent with leptomeningeal lymphomatosis. A whole-body positron emission tomography scan disclosed a mediastinal mass, whose histopathologic "starry sky" appearance was pathognomonic for BL. CONCLUSIONS: Reviewing the literature, we were able to find only 3 cases of OMP as the presenting manifestation of BL, all occurring in patients with predisposing HIV infection.Our case of isolated OMP highlights some "red flags" for a lymphomatous etiology, including young age, a progressive course, a response to high-dose steroid therapy, and relapse upon steroid discontinuation; these cases require a comprehensive evaluation, including repeated cytological cerebrospinal fluid analysis and sensitive imaging techniques to detect a possible primary lesion.

Isolated third nerve palsy: a rare neurological presentation of Burkitt's lymphoma.

Lymphoma patient presenting with isolated third nerve palsy is relatively rare, and diagnosis of underlying disease may be challenging. Until this date, less than 20 cases have been described in the literature. This is the case of a 3-year-old boy who presented to neurologist with ptosis of left eye for 8 days. On examination, abdominal mass was detected, and the child was referred to paediatric surgery department. Laparotomy and excision of the mass was done. Histopathology and immunohistochemistry of the mass confirmed it to be a case of Burkitt's lymphoma. At this point, the patient was referred to haematology department. Contrast-enhanced CT brain showed infiltration around left cavernous sinus. Patient was treated with two cycles of R-CODOX-M/R-IVAC. Ptosis improved completely within few days of starting chemotherapy. Follow-up positron emission tomography CT scan done after the second cycle of chemotherapy revealed no metabolically active disease.

Oculomotor Abnormalities in Children with Attention-Deficit/Hyperactivity Disorder Are Improved by Methylphenidate.

BACKGROUND: There are relatively few studies of saccadic eye movements in children with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to examine inhibitory abilities of eye movements in children with ADHD and to explore the effect of methylphenidate (MPH) on eye movement performance. METHODS: Thirty-one children with ADHD (mean age 9.9 ± 0.4 years) and 31 sex-, age-, and IQ-matched children with normal development were examined. Saccades elicited not only by the gap, step, overlap, and antisaccade paradigms but also a simple fixation paradigm have been recorded using an eye tracker. The latency of each type of saccade, the error rate of antisaccades, and the number of saccades made during fixation have been measured. RESULTS: Children with ADHD and naive to treatment with respect to controls showed significantly shorter mean latency of voluntary saccades (overlap paradigm), more frequent errors during the antisaccade paradigm, and higher number of saccades made during fixation. After 1 month of MPH treatment, all these parameters changed significantly and reached control values. CONCLUSION: Taken together, these results suggest that oculomotor abilities are poor in children with ADHD, which may correlate with deficits in inhibitory mechanisms. Treatment with MPH improves oculomotor performances through adaptive strategies, which may involve brain structures related to cognitive inhibition.