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Mohebbi M, Nafissi S, Alikhani M. A New Case of Granulomatosis with Polyangiitis Presented with Tolosa-Hunt Syndrome Manifestations. Case Rep Rheumatol 2024; 2024:5552402. [PMID: 38288297 PMCID: PMC10824575 DOI: 10.1155/2024/5552402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 01/31/2024] Open
Abstract
Background Tolosa-Hunt syndrome (THS) is a rare disorder involving the orbital and retro-orbital space. The typical symptoms include sensory loss in the trigeminal nerve's distribution, orbital pain, swelling, headaches, and cranial nerve palsies. Case Presentation. We report a 40-year-old female who initially presented with biparietal headache, unresponsive to medication, which then led to ophthalmoplegia and orbital pain. Serological findings demonstrated positive CANCA-PR3. She was initially treated with 1 g pulse methylprednisolone for three days. Based on the rheumatological evaluation and her positive lung nodule, hematuria, dysmorphic red blood cells, and positive antiproteinase 3 classic antineutrophil cytoplasm antibodies (CANCA-PR3) and also based on the diagnostic criteria for granulomatosis with polyangiitis criteria for Wegner disease, her treatment was continued with prednisolone 1 mg/kg and also rituximab at the first and 14th day of treatment. Conclusion In our case of THS, we achieved satisfactory improvement in symptoms through the administration of high-dose steroids.
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Affiliation(s)
- Maryam Mohebbi
- Department of Internal Medicine, School of Medicine, Rheumatology Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahriar Nafissi
- Department of Neurology, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Alikhani
- Department of Internal Medicine, School of Medicine, Rheumatology Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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2
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Disseminated tuberculosis masquerading as Tolosa-Hunt syndrome in initial presentation: A case report with literature review. Radiol Case Rep 2023; 18:1353-1357. [PMID: 36712191 PMCID: PMC9873575 DOI: 10.1016/j.radcr.2023.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/07/2023] [Indexed: 01/22/2023] Open
Abstract
Tolosa-Hunt syndrome (THS) is a painful ophthalmoplegia due to non-specific granulomatous inflammation in the cavernous sinus region. It is diagnosed by the International Classification of Headache Disorders (ICHD)-3 criteria. We report the case of a young lady who presented with a right-sided headache for 2 weeks, followed by right-sided diplopia for 4 days. Clinical examination revealed right trochlear nerve palsy. Magnetic resonance imaging (MRI) of her brain showed abnormal thickening and postcontrast enhancement of the right orbital apex and superior orbital fissure, suggesting THS. Examination of cerebrospinal fluid (CSF) ruled out intracranial infection. The initial presentation satisfied the ICHD-3 criteria. Further imaging revealed cervical, axillary, and intra-abdominal lymphadenopathy with granulomatous lesions in the spleen and right kidney. Ultrasound (US)-guided axillary lymph node biopsy was positive for Mycobacterium tuberculosis. QuantiFERON TB gold plus test from serum was positive. Based on radiological and histopathological findings, a diagnosis of disseminated tuberculosis involving lymph nodes, kidneys, spleen, and lungs was made. THS is a diagnosis of exclusion. This case signifies that patients diagnosed with THS based on ICHD-3 criteria should be extensively evaluated to rule out granulomatous infections such as tuberculosis. Typical THS symptoms with granulomatous inflammation can give false reassurance to clinicians and prevent investigation for more dangerous etiologies. As painful ophthalmoplegia can arise secondary to a myriad of pathologies, diagnostic workups for all possibilities should be exhausted before arriving at a diagnosis of THS. Regardless of MRI findings, workups for tuberculosis and fungal infections should be completed.
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3
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He W, Zhu Y, Zhang Y, Dong L, Zhou Z, Zhou J. A case report on recurrent alternating Tolosa-Hunt syndrome due to bacterial sphenoid sinusitis: rediscussing the diagnostic terminology and classification. BMC Neurol 2023; 23:25. [PMID: 36650509 PMCID: PMC9843661 DOI: 10.1186/s12883-023-03067-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Tolosa-Hunt syndrome (THS) is characterized by painful ophthalmoplegia caused by idiopathic granulomatous inflammation involving the cavernous sinus region. Patients respond well to steroid therapy. THS is included in the differential diagnosis of cavernous sinus syndrome, so it is important to fully exclude other lesions in this area before treatment, otherwise steroid treatment may lead to fatal outcomes. Here we describe a patient who initially presented with symptoms that simulated THS symptoms and developed recurrent alternating painful ophthalmoplegia during follow-up, and the patient was finally diagnosed with cavernous sinusitis caused by bacterial sphenoid sinusitis. CASE PRESENTATION A 34-year-old woman presented with left painful ophthalmoplegia. Magnetic resonance imaging (MRI) revealed abnormal signals in the left cavernous sinus area, and these abnormal signals were suspected to be THS. After steroid treatment, the patient obtained pain relief and had complete recovery of her ophthalmoplegia. However, right painful ophthalmoplegia appeared during the follow-up period. MRI showed obvious inflammatory signals in the right cavernous sinus and right sphenoid sinus. Then nasal sinus puncture and aspiration culture were performed, and the results showed a coagulase-negative staphylococcus infection. After antibiotic treatment with vancomycin, the painful ophthalmoplegia completely resolved, and the neurological examination and MRI returned to normal. CONCLUSION Some other causes of painful ophthalmoplegia also fulfill the diagnostic criteria for THS in the International Classification of Headache Disorders third edition (ICHD-3) and respond well to steroid therapy. Early diagnosis of THS may be harmful to patients, and clinicians should exercise great caution when dealing with similar cases without a biopsy. Using "cavernous sinus syndrome" instead of "Tolosa-Hunt syndrome" as a diagnostic category may provide a better clinical thinking for etiological diagnosis.
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Affiliation(s)
- Wei He
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Branch of The First Affiliated Hospital of Chongqing Medical University, 191st Ren Min Road, Yu Zhong District, Chongqing, 400015 China
| | - Yinglin Zhu
- grid.258405.e0000 0004 0539 5056School of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Joplin, MO 64801 USA
| | - Yinan Zhang
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Branch of The First Affiliated Hospital of Chongqing Medical University, 191st Ren Min Road, Yu Zhong District, Chongqing, 400015 China
| | - Liang Dong
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1st You Yi Road, Yu Zhong District, Chongqing, 400016 China
| | - Zefang Zhou
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Branch of The First Affiliated Hospital of Chongqing Medical University, 191st Ren Min Road, Yu Zhong District, Chongqing, 400015 China
| | - Jiying Zhou
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1st You Yi Road, Yu Zhong District, Chongqing, 400016 China
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4
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Sun P, Liu Y, Zhou M, Liu Y, Du J, Zeng G. Abscess of the cavernous sinus in a child: a case report. Childs Nerv Syst 2022; 38:1987-1991. [PMID: 35608661 DOI: 10.1007/s00381-022-05539-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The cavernous sinus, which has several important structures, can be affected by various lesions, including tumor, vascular, infection, and inflammation. CASE REPORT We reported a rare case of abscess of the cavernous sinus in a child presenting with headache and abducens paralysis. Exploratory surgery was performed via the Dolenc approach, and the patient recovered from abducens paralysis 3 months later. CONCLUSION Abscess of the cavernous sinus is rare. Inspection of cavernous sinus can confirm the characteristics of the lesion and decompress the cavernous sinus, which may be beneficial for nerve function recovery.
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Affiliation(s)
- Peng Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mading Zhou
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yutong Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianxin Du
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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5
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Dutta P, Anand K. Tolosa-Hunt Syndrome: A Review of Diagnostic Criteria and Unresolved Issues. J Curr Ophthalmol 2021; 33:104-111. [PMID: 34409218 PMCID: PMC8365592 DOI: 10.4103/joco.joco_134_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 11/04/2022] Open
Abstract
Purpose: To review the diagnostic criteria for Tolosa–Hunt syndrome (THS) and utility of recent modifications. Methods: We searched PubMed for keywords Tolosa Hunt and magnetic resonance imaging. We compared the three editions of International Classification of Headache Disorders and isolated case reports and case series with the assessment of cavernous internal carotid artery (ICA) caliber to find the prevalence of vascular anomalies. We also evaluated cases of THS with the involvement of extracavernous structures and the possible role of idiopathic hypertrophic pachymeningitis (HP). Cases diagnosed falsely as THS were also reviewed for the presence of atypical features and relevance of criterion D. We assessed nonconforming cases (those with normal neuroimaging benign THS) and idiopathic inflammatory orbital pseudotumor (IIPO). Results: Vascular abnormalities were found in 36.36% of THS cases. Benign THS may also show changes in ICA caliber. Evidence suggestive of idiopathic HP could be found in 57% of cases with the involvement of extracavernous structures, such as facial nerve and pituitary gland. Both THS and IIPO are steroid-responsive pathologies with similar clinical and radiological features. False-positive diagnosis of THS results from early labeling, based solely on clinical features and symptom resolution after steroid therapy. Conclusions: Benign THS may be a result of limitation of resolution of available neuroimaging technique or early testing. Early and late vascular changes can be seen in both THS and its benign variant; some of them are not innocuous. THS may be considered a type of focal idiopathic HP. IIPO may represent an anterior variant of THS. In the absence of histopathological diagnosis, steroid-induced resolution of symptoms should be confirmed radiologically and followed-up.
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Affiliation(s)
- Paromita Dutta
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
| | - Kamlesh Anand
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
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6
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Tolosa-Hunt Syndrome: A Painful Ophthalmoplegia. Case Rep Neurol Med 2020; 2020:8883983. [PMID: 33204552 PMCID: PMC7666634 DOI: 10.1155/2020/8883983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/04/2020] [Accepted: 10/31/2020] [Indexed: 02/05/2023] Open
Abstract
Tolosa–Hunt syndrome is a painful ophthalmoplegia characterized by recurrent unilateral orbital pain, ipsilateral oculomotor paralysis, and a rapid response to steroids. Our report describes a 37-year-old young woman who presented with right ptosis, ipsilateral ophthalmoplegia, and painful headache with no other neurological deficits in which all biological and neuroimaging investigations were normal. Complete recovery within one week of corticosteroid therapy was observed. This is probably the first case of Tolosa–Hunt syndrome reported in Dakar, Senegal.
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7
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Mullen E, Rutland JW, Green MW, Bederson J, Shrivastava R. Reappraising the Tolosa‐Hunt Syndrome Diagnostic Criteria: A Case Series. Headache 2019; 60:259-264. [DOI: 10.1111/head.13692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Evan Mullen
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai New York NY USA
| | - John W. Rutland
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai New York NY USA
| | - Mark W. Green
- Department of Neurology Icahn School of Medicine at Mount Sinai New York NY USA
| | - Joshua Bederson
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai New York NY USA
| | - Raj Shrivastava
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai New York NY USA
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8
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Hötte GJ, Koudstaal MJ, Verdijk RM, Titulaer MJ, Claes JFHM, Strabbing EM, van der Lugt A, Paridaens D. Intracranial actinomycosis of odontogenic origin masquerading as auto-immune orbital myositis: a fatal case and review of the literature. BMC Infect Dis 2019; 19:763. [PMID: 31477035 PMCID: PMC6720412 DOI: 10.1186/s12879-019-4408-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/25/2019] [Indexed: 11/13/2022] Open
Abstract
Background Actinomycetes can rarely cause intracranial infection and may cause a variety of complications. We describe a fatal case of intracranial and intra-orbital actinomycosis of odontogenic origin with a unique presentation and route of dissemination. Also, we provide a review of the current literature. Case presentation A 58-year-old man presented with diplopia and progressive pain behind his left eye. Six weeks earlier he had undergone a dental extraction, followed by clindamycin treatment for a presumed maxillary infection. The diplopia responded to steroids but recurred after cessation. The diplopia was thought to result from myositis of the left medial rectus muscle, possibly related to a defect in the lamina papyracea. During exploration there was no abnormal tissue for biopsy. The medial wall was reconstructed and the myositis responded again to steroids. Within weeks a myositis on the right side occurred, with CT evidence of muscle swelling. Several months later he presented with right hemiparesis and dysarthria. Despite treatment the patient deteriorated, developed extensive intracranial hemorrhage, and died. Autopsy showed bacterial aggregates suggestive of actinomycotic meningoencephalitis with septic thromboembolism. Retrospectively, imaging studies showed abnormalities in the left infratemporal fossa and skull base and bilateral cavernous sinus. Conclusions In conclusion, intracranial actinomycosis is difficult to diagnose, with potentially fatal outcome. An accurate diagnosis can often only be established by means of histology and biopsy should be performed whenever feasible. This is the first report of actinomycotic orbital involvement of odontogenic origin, presenting initially as bilateral orbital myositis rather than as orbital abscess. Infection from the upper left jaw extended to the left infratemporal fossa, skull base and meninges and subsequently to the cavernous sinus and the orbits. Electronic supplementary material The online version of this article (10.1186/s12879-019-4408-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G J Hötte
- Department of Ophthalmology, Erasmus Medical Center, Rotterdam, The Netherlands. .,Department of Orbital Oculoplastic and Lacrimal Surgery, The Rotterdam Eye Hospital, PO box 70030, 3000 LM, Rotterdam, The Netherlands.
| | - M J Koudstaal
- Department of Oral and Maxillofacial Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - R M Verdijk
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M J Titulaer
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J F H M Claes
- Department of Neurology, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - E M Strabbing
- Department of Oral and Maxillofacial Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - A van der Lugt
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - D Paridaens
- Department of Ophthalmology, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Orbital Oculoplastic and Lacrimal Surgery, The Rotterdam Eye Hospital, PO box 70030, 3000 LM, Rotterdam, The Netherlands
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9
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Orbital and Pulmonary Actinomycosis: The First Case Report and Literature Review. Case Rep Infect Dis 2018; 2018:4759807. [PMID: 30147972 PMCID: PMC6083539 DOI: 10.1155/2018/4759807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/09/2018] [Indexed: 11/17/2022] Open
Abstract
Orbital actinomycosis is a very rare clinical manifestation of orbital infection caused by Actinomyces species, anaerobic Gram-positive filamentous bacteria. We report herein a case of a 58-year-old man who presented with chronic progressive course of total ophthalmoparesis in association with productive cough, leading to the diagnosis after extensive investigation. In addition, all reported cases of orbital actinomycosis in the literature are reviewed.
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10
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Lubomski M, Dalgliesh J, Lee K, Damodaran O, McKew G, Reddel S. Actinomyces cavernous sinus infection: a case and systematic literature review. Pract Neurol 2018; 18:373-377. [PMID: 29650638 DOI: 10.1136/practneurol-2017-001844] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/09/2018] [Accepted: 04/02/2018] [Indexed: 01/03/2023]
Abstract
A 63-year-old man presented with a 2-month history of progressive right-sided exophthalmos, painful ophthalmoplegia and fevers. As more features developed, he was diagnosed with giant cell arteritis, then Tolosa-Hunt syndrome, and transiently responded to corticosteroids. A bland cerebrospinal fluid and highly metabolically active brain (18F)-fluoro-D-glucose-positron emission tomography suggested lymphoma. Biopsy of the mass showed sulphur granules with Gram-positive filamentous bacteria with Actinomyces-like colonies. Actinomyces cavernous sinus infections are rare and indolent. They often mimic non-infective causes including other inflammatory and infiltrative conditions, vascular and neoplastic causes, particularly lymphoma. Clinicians should consider infective cavernous sinus syndromes in people with a fluctuating painful ophthalmoplegia that responds poorly to corticosteroids. The term Tolosa-Hunt syndrome is problematic and should be retired or used only with reservation.
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Affiliation(s)
- Michal Lubomski
- Department of Neurology, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - James Dalgliesh
- Department of Ophthalmology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Kenneth Lee
- Department of Anatomical Pathology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Omprakash Damodaran
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Genevieve McKew
- Department of Infectious Disease, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Concord Clinical School, The University of Sydney, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Stephen Reddel
- Department of Neurology, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Concord Clinical School, The University of Sydney, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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11
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Carreón E, Muñiz S, Di Capua D, Porta-Etessam J. Tolosa-Hunt syndrome with spontaneous remission and recurrence. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2015.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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12
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Mullen E, Green M, Hersh E, Iloreta AM, Bederson J, Shrivastava R. Tolosa-Hunt Syndrome: Appraising the ICHD-3 beta diagnostic criteria. Cephalalgia 2017; 38:1696-1700. [DOI: 10.1177/0333102417745271] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction The term Tolosa-Hunt Syndrome was first used more than half a century ago to describe painful ophthalmoplegia accompanied by cranial nerve palsies. In the decades since, its diagnostic criteria have evolved considerably. The beta version of the 3rd Edition of the International Classification of Headache Disorders narrows these criteria to require the demonstration of granulomatous inflammation on MRI or biopsy. We believe this may introduce challenges to accurate diagnosis. Discussion Requiring the demonstration of granulomatous inflammation for a diagnosis of Tolosa-Hunt Syndrome may introduce the potential for false negative and false positive diagnoses. Although the disorder presents secondary to granulomatous inflammation, MRI technology may not be able to identify it reliably, and biopsy is not always indicated for its symptomatology. Additionally, several cases have been reported of Tolosa-Hunt Syndrome diagnosed with MRI-confirmed granulomatous inflammation that later prove to be attributable to other pathologies. The emphasis on neuroimaging may therefore exclude some true Tolosa-Hunt Syndrome cases and include others resulting from other latent pathologies that are not visible on MRI. Conclusion We wish to offer several potential modifications to the International Classification of Headache Disorders guidelines for Tolosa-Hunt Syndrome, including making the demonstration of granulomatous inflammation on MRI or biopsy non-mandatory and lengthening patient follow-up to two years for cases in which MRI is unrevealing.
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Affiliation(s)
- Evan Mullen
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mark Green
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eliza Hersh
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alfred-Marc Iloreta
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raj Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Laura Asillo E, Román Pérez F, Valdez González J, Pérez Guerra E, Matos Rojas I. Una presentación infrecuente de un síndrome poco frecuente. Semergen 2016; 42:e73-5. [DOI: 10.1016/j.semerg.2015.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 07/20/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
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14
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Carreón E, Muñiz S, Di Capua D, Porta-Etessam J. Tolosa-Hunt syndrome with spontaneous remission and recurrence. Neurologia 2016; 33:68-70. [PMID: 26976551 DOI: 10.1016/j.nrl.2015.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/13/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- E Carreón
- Servicio de Neurología, Hospital Universitario Virgen de la Arrixaca, Murcia, España
| | - S Muñiz
- Servicio de Neurología, Unidad de Cefaleas, Hospital Clínico Universitario San Carlos, Madrid, España
| | - D Di Capua
- Servicio de Neurología, Unidad de Cefaleas, Hospital Clínico Universitario San Carlos, Madrid, España
| | - J Porta-Etessam
- Servicio de Neurología, Unidad de Cefaleas, Hospital Clínico Universitario San Carlos, Madrid, España.
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15
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Kastirr I, Kamusella P, Andresen R. Bilateral Painful Ophthalmoplegia: A Case of Assumed Tolosa-Hunt Syndrome. J Clin Diagn Res 2016; 10:TD16-7. [PMID: 27134970 DOI: 10.7860/jcdr/2016/16703.7496] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 12/11/2015] [Indexed: 01/03/2023]
Abstract
We present the case of a man of 47 years with vertical and horizontal paresis of view combined with periorbital pain that developed initially on the right side but extended after 3-4 days to the left. Gadolinum uptaking tissue in the cavernous sinus was shown by MRI of the orbital region in the T1 spin echo sequence with fat saturation (SEfs) with a slice thickness of 2 mm. As no other abnormalities were found and the pain resolved within 72 hours of treatment with cortison a bilateral Tolosa-Hunt Syndrome (THS) was assumed. THS is an uncommon cause for Painful Ophthalmoglegia (PO) and only few cases of bilateral appearance have been reported. Even though the diagnostic criteria for THS oblige unilateral symptoms we suggest that in patients with bilateral PO THS should not be excluded as a differential diagnosis. Further more when using MRI to detect granulomatous tissue in the orbital region the chosen sequence should be T1 SEfs and slice thickness should possibly be as low as 2 mm, as granulomas are often no larger than 1-2 mm.
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Affiliation(s)
- Ilko Kastirr
- Medical Assistant, Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel , Lübeck and Hamburg, Germany
| | - Peter Kamusella
- Medical Specialist, Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel , Lübeck and Hamburg, Germany
| | - Reimer Andresen
- Head of Department, Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel , Lübeck and Hamburg, Germany
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16
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Douleh DG, Morone PJ, Johnson JE, Paueksakon P, Wellons JC. Actinomycosis Mimicking Tolosa-Hunt Syndrome in a 6-Year-Old Boy: Case Report. Pediatr Neurosurg 2016; 51:214-7. [PMID: 27070954 DOI: 10.1159/000444940] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/20/2016] [Indexed: 11/19/2022]
Abstract
Tolosa-Hunt syndrome is an idiopathic inflammatory process of the cavernous sinus or orbit manifesting as painful ophthalmoplegia. In this report, we detail the case of a 6-year-old boy who presented with several weeks of unilateral headache and diplopia. He was found to have an infiltrative process involving the bilateral cavernous sinuses and pituitary gland on MRI. Given a progressing infiltrative central nervous system process on repeat MRI and the development of cerebral salt wasting, a biopsy was performed revealing actinomycosis. To our knowledge, this is the first reported case of actinomycosis masquerading as Tolosa-Hunt syndrome in a child.
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Affiliation(s)
- Diana G Douleh
- Vanderbilt University School of Medicine, Nashville, Tenn., USA
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17
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Conforti R, Cirillo M, Marrone V, Galasso R, Capaldo G, Giugliano T, Scuotto A, Piluso G, Melone MA. Giant thrombosed intracavernous carotid artery aneurysm presenting as Tolosa-Hunt syndrome in a patient harboring a new pathogenic neurofibromatosis type 1 mutation: a case report and review of the literature. Neuropsychiatr Dis Treat 2014; 10:135-40. [PMID: 24476631 PMCID: PMC3901779 DOI: 10.2147/ndt.s49784] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Neurofibromatosis type 1 (NF1) is a relatively common single-gene disorder, and is caused by heterozygous mutations in the NF1 gene that result in a loss of activity or in a nonfunctional neurofibromin protein. Despite the common association of NF1 with neurocutaneous features, its pathology can extend to numerous tissues not derived from the neural crest. Among the rare cerebrovascular abnormalities in NF1, more than 85% of cases are of purely occlusive or stenotic nature, with intracranial aneurysm being uncommon. Predominantly, the aneurysms are located in the internal carotid arteries (ICAs), being very rare bilateral aneurysms. This report describes a very unusual case of fusiform aneurysms of both ICAs in a Caucasian NF1 patient, with a new pathogenic intragenic heterozygous deletion of the NF1 gene, presenting at age 22 years with Tolosa-Hunt syndrome, because of partial thrombosis of the left giant intracavernous aneurysm. Medical treatment with anticoagulant therapy allowed a good outcome for the patient. In conclusion, early identification of cerebral arteriopathy in NF1 and close follow-up of its progression by neuroimaging may lead to early medical or surgical intervention and prevention of significant neurologic complications.
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Affiliation(s)
- Renata Conforti
- Neuroradiology Unit, Department of Clinical and Experimental Medicine and Surgery
| | - Mario Cirillo
- Radiology Unit, Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences
| | - Valeria Marrone
- Neuroradiology Unit, Department of Clinical and Experimental Medicine and Surgery
| | - Rosario Galasso
- Neuroradiology Unit, Department of Clinical and Experimental Medicine and Surgery
| | - Guglielmo Capaldo
- Division of Neurology, Department of Clinical and Experimental Medicine and Surgery
| | - Teresa Giugliano
- Department of Biochemistry, Biophysics and General Pathology, School of Medicine, Second University of Naples, Naples, Italy
| | - Assunta Scuotto
- Neuroradiology Unit, Department of Clinical and Experimental Medicine and Surgery
| | - Giulio Piluso
- Department of Biochemistry, Biophysics and General Pathology, School of Medicine, Second University of Naples, Naples, Italy
| | - Mariarosa Ab Melone
- Division of Neurology, Department of Clinical and Experimental Medicine and Surgery ; Institute of Protein Biochemistry, National Research Council, Naples, Italy
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Carrieri PB, Montella S, Petracca M, Cerullo G, Elefante A. Tolosa-Hunt syndrome in a patient with autoimmune hemolytic anemia. Int J Neurosci 2010; 120:680-2. [PMID: 20718692 DOI: 10.3109/00207454.2010.510915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Tolosa-Hunt syndrome is a steroid responsive painful opthalmoplegia due to a nonspecific inflammation of the cavernous sinus. Autoimmune hemolytic anemia is caused by antibodies directed against unmodified autologous red cells. They are both rare conditions. Here we describe the simultaneous occurrence of Tolosa-Hunt syndrome and severe hemolytic crisis in the same patient.
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Tolosa–Hunt syndrome with reversible dissection aneurysm. Neurol Sci 2010; 31:777-9. [DOI: 10.1007/s10072-010-0231-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 01/22/2010] [Indexed: 10/19/2022]
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Gladstone JP. An approach to the patient with painful ophthalmoplegia, with a focus on Tolosa-Hunt syndrome. Curr Pain Headache Rep 2007; 11:317-25. [PMID: 17686398 DOI: 10.1007/s11916-007-0211-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The differential diagnosis of painful ophthalmoplegia is extensive and consists of numerous sinister etiologies, including neoplasms (ie, primary intracranial tumors, local or distant metastases), vascular (eg, aneurysm, carotid dissection, and carotid-cavernous fistula), inflammatory (ie, orbital pseudotumor, giant cell arteritis, sarcoidosis, and Tolosa-Hunt syndrome), and infectious etiologies (ie, fungal and mycobacterial), as well as other miscellaneous conditions (ie, ophthalmoplegic migraine and microvascular infarcts secondary to diabetes). A systematic approach to the evaluation of painful ophthalmoplegia can lead to prompt recognition of serious disorders that can be associated with significant morbidity or mortality if left untreated. Inflammatory conditions such as Tolosa-Hunt syndrome and orbital pseudotumor are highly responsive to corticosteroids but should be diagnoses of exclusion.
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Besada E, Hunter M, Bittner B. An uncommon presentation of orbital apex syndrome. ACTA ACUST UNITED AC 2007; 78:339-43. [PMID: 17601571 DOI: 10.1016/j.optm.2007.04.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Revised: 04/09/2007] [Accepted: 04/09/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bilateral total ophthalmoplegia secondary to a malignancy or infection of the cavernous sinus and orbital apex is an unusual presentation. Bilateral ophthalmoplegia as the initial sign of this type of rhinocerebral pathology is also uncommon. CASE REPORT A 34-year old Haitian woman presented with bilateral vision loss, ptosis, total ophthalmoplegia, and ocular pain. A physical and neurologic examination, laboratory analysis, chest x-rays, and neurologic imaging studies were requested. Cranial and facial computed tomography (CT) scans showed swelling of the soft tissues proximal to the sphenoid extending into the dorsal sella and prepontine cistern, obliteration of the nasopharyngeal reflection, opacification of the ethmoid and sphenoid sinus, bony destruction of the mid-skull base, and bilateral lymphadenopathy of the neck. Magnetic resonance imaging (MRI) showed the presence of a soft tissue mass causing destruction of the skull base. Involvement of the clivus, cavernous sinuses, and sella with nasopharynx extension was observed. Hypodense centers within nasopharyngeal tissues suggested the presence of necrosis. Differential diagnosis included nasopaharyngeal carcinoma, lymphoma, or an infectious process. The patient did not consent to a biopsy and refused treatment. CONCLUSION This presentation is a medical emergency. A combination of surgical, medical, or radiological intervention may be required to manage rhino-cerebral diseases responsible for orbital apex syndrome. Despite advances in neurologic imaging, histologic examination of tissue obtained from a biopsy may ultimately be necessary to obtain a precise diagnosis.
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Affiliation(s)
- Eulogio Besada
- Nova Southeastern University College of Optometry, Ft. Lauderdale, Florida 33162, USA.
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Abstract
We review the question of diagnosis of painful and relatively isolated ophthalmoplegia due to diseases affecting the ocular motor nerves. For each clinical setting, we provide an overview of the main causes and a practical way to approach the diagnosis. As vascular malformations should always be kept in mind in patients with painful ophthalmoplegia, emergency neuroradiological investigations may be needed. However, the etiological scope is wide and the rationale for choosing the more appropriate examination and its optimal timing depends exclusively on the clinical evaluation. Despite advances in investigation techniques, diagnosis may remain difficult or even unresolved in a certain number of patients. We discuss successively paralysis of the third, sixth and fourth nerve, paralysis of several ocular motor nerves, recurrent ophthalmoplegia and ischaemic ocular motor palsies, which are the most frequent cause.
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Affiliation(s)
- A Vighetto
- Service de Neurologie D, Hôpital neurologique Pierre-Wertheimer et Université Claude-Bernard Lyon I, Lyon.
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