Orbital actinomycosis associated with painful ophthalmoplegia. Actinomycosis of the orbit

Tolosa-Hunt Syndrome: A Review of Diagnostic Criteria and Unresolved Issues

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.

Intracranial actinomycosis of odontogenic origin masquerading as auto-immune orbital myositis: a fatal case and review of the literature

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.

Physiotherapy in Postinfection Injury to Cranial Nerves III, IV, and VI: A Case Study

The patient with bacterial infection sequelae in the form of damage to cranial nerves III, IV, and VI was followed up. He had exhibited clinical and radiographic signs of paranasal sinusitis. Before his physiotherapy, the patient received standard treatment with natural and synthetic antibiotics and steroids. After acute signs of infection resolved without any functional improvement, the patient was referred to a rehabilitation unit to undergo neuromuscular re-education of the paralyzed extraocular muscles. Periorbital hydrocortisone iontophoresis and visuomotor exercises with intense ideomotor stimulation led to complete and rapid resolution of extraocular muscle paralysis and diplopia. Physiotherapy can be an effective treatment of choice after failed pharmacological treatment in patients with damage to cranial nerves III and VI. It has many theoretical advantages, including noninvasiveness and avoidance of first-pass metabolism of drugs administered systemically.

Orbital and Pulmonary Actinomycosis: The First Case Report and Literature Review

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.

Actinomyces cavernous sinus infection: a case and systematic literature review

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.

Imaging lesions of the cavernous sinus

Our aim was to review the imaging findings of relatively common lesions involving the cavernous sinus (CS), such as neoplastic, inflammatory, and vascular ones. The most common are neurogenic tumors and cavernoma. Tumors of the nasopharynx, skull base, and sphenoid sinus may extend to the CS as can perineural and hematogenous metastases. Inflammatory, infective, and granulomatous lesions show linear or nodular enhancement of the meninges of the CS but often have nonspecific MR imaging features. In many of these cases, involvement elsewhere suggests the diagnosis. MR imaging is sensitive for detecting vascular lesions such as carotid cavernous fistulas, aneurysms, and thromboses.

[Actinomycosis: an unusual cause of spinal cord compression. Case report and review of the literature]

Actinomycosis is an unusual and unrecognized cause of spinal cord compression of infectious origin. We report the case of a 57-year-old immunocompetent woman admitted for sub-acute lower limb ataxia. The diagnosis of spinal cord compression secondary to actinomyces infectious arthritis was established. Surgical decompression and long-term antibiotic treatment enabled complete recovery. Data from the literature indicate that actinomycosis is a potential cause of several neurological manifestations. Unusual but treatable, actinomycosis is a potential alternative when the main etiologies have been ruled out.

Delayed-onset Actinomyces keratitis after laser in situ keratomileusis

PURPOSE

To present a case of delayed-onset unilateral keratitis caused by Actinomyces israelii after laser in situ keratomileusis (LASIK).

METHODS

A 28-year-old woman was referred to our clinic because of foreign-body sensation and mild blurred vision in her left eye. She had bilateral simultaneous LASIK approximately 5 months ago. On slit-lamp examination, there was an area of infiltration in the corneal interface. The LASIK flap was elevated, and the involved area was scraped and irrigated with antibiotic solutions.

RESULTS

Culture and smear showed A. israelii as a causative agent, and the keratitis was successfully treated by antibiotics chosen according to antibiotic sensitivity test.

CONCLUSIONS

Actinomyces israelii must be considered in differential diagnosis of delayed-onset microbial keratitis after LASIK. Flap elevation, scraping, and irrigating the involved area can be helpful to obtain specimens for culture and smear and to control infection.

Rhino-orbito-cerebral mucormycosis: report of two cases and review of the literature

Rhino-orbito-cerebral mucormycosis (ROCM) is a rare, fulminant opportunistic fungal infection that is mostly seen in immunocompromised or diabetic patients. The disease should be recognised and treated immediately. We present here MR imaging findings of two patients with histopathologically proven ROCM. One of the cases had a history of corticosteroid treatment and iatrogenic diabetes mellitus and although amphotericin B was started immediately, the disease progressed and surgical debridement was necessary. The second case was a patient with diabetes mellitus type 1 in whom ROCM had occurred following an abdominal surgery; amphotericin B treatment alone was adequate in this patient.

Periocular infection

PURPOSE OF REVIEW

The aim of this article is to acquaint the clinician with advances in the diagnosis and management of periocular cellulitis and to alert physicians to emerging pathogens.

RECENT FINDINGS

The most important, recent infectious disease entity to consider is community-acquired methicillin-resistant Staphylococcus aureus, which is emerging as a significant problem across the country. The potential devastation caused by necrotizing fasciitis is also reviewed, since this diagnosis is easily missed early in its course. A variety of less common and frankly atypical pathogens is presented to remind the clinician that, on occasion, the hoofbeats are indeed a zebra's.

SUMMARY

Periocular cellulitis remains an important and common entity in ophthalmology. The emergence of new pathogens and the resistance to conventional treatment by others are a cause for concern and require an understanding of management strategies.