Clinical Reasoning: A 22-year-old man with diplopia

Abstract

A 22-year-old previously healthy man presented to an ophthalmology clinic with binocular horizontal diplopia. He had recently traveled to the main island of Hawaii. About 2 weeks after returning home, he developed a severe headache with associated fever, emesis, photophobia, phonophobia, and neck stiffness. He also reported a sensation of pressure in his left eye and both ears but denied any pulsatile tinnitus or transient vision loss. Over the next 2 weeks, his headaches worsened, causing him to wake up frequently in the night. He then developed horizontal diplopia that was worse at a distance and was referred to the neuro-ophthalmology clinic.Examination. The patient had some limitation in neck flexion with associated pain. His visual acuity was 20/20 on the right and 20/25 on the left. Pupillary examination showed no relative afferent defect and visual fields were full. He was found to have bilateral abducens palsy with an esotropia of 30 D and a left hypertropia of 2 D with notable mild right head tilt. The hypertropia was thought to be a partial left 4th nerve palsy with a compensatory right head tilt, although a full Parks-Bielschowsky 3-step test was not preformed to confirm this. He had moderate to severe papilledema on funduscopic examination ( figure, A). The remainder of his neurologic and ophthalmologic examination was within normal limits. Questions for consideration:1. Given his papilledema and bilateral abducens nerve palsy, where would you localize this? 2. What is the differential diagnosis for bilateral abducens nerve palsy?

Epidemiological, clinical and laboratory aspects of Angiostrongylus cantonensis infection: an integrative review

“…Other cases also used the surgical removal of the worm at the ocular level, as well as lumbar puncture to treat cranial hypertension resulting from meningitis. Some unconventional treatments were also used, such as acupuncture and cannabis use, but no results about clinical improvements by these treatments were presented (Meyer et al, 2017;Nguyen et al, 2017;Andrade et al, 2018).…”

“…Both eyes had grade II nuclear sclerosis. He underwent surgical removal of the live worm in order to avoid blindness or systemic damage, thus having a good prognosis (Tiwari et al, 2019;Meyer et al, 2017).…”

“…About the brain findings, several types of lesions were identified through MRI. Overall, patients had nodular lesions in the cortex and optic nerve, diffuse stippled areas of cortical infarctions, hyperintense signal on T2-weighted images, signs of leukoencephalopathy, abnormal T2 and FLAIR signals in the cerebellar hemisphere and occipital lobe, which were clinically manifested by diplopia, papilledema, VI cranial nerve palsy, paroxysmal dizziness and mainly headache (Hammoud et al, 2017;Meyer et al, 2017;Prasidthrathsint et al, 2017;Zhang et al, 2020).…”

“…Some studies with infected patients by A. cantonensis showed alterations in other complementary exams, such as one by Meyer et al (2017), whose non-contrast chest CT demonstrated multiple peripheral nodules in the lungs, and the case by Nguyen et al (2017), in which chest and abdominal CT showed hepatic hypodensity. Other changes found in other case reports were a high-intensity nodule located in the posterior lateral segment of the lower lobe of the right lung, which after treatment with albendazole (40 mg/day) for 21 days and dexamethasone (10 mg/ day) for 16 days improved and the nodule disappeared (Wang et al, 2018).…”