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 Missouri Resident Poster Competition 1999 Muhammad Hussain M.D.
Univ.
of Missouri--Columbia A 72 year old caucasian male had onset of pain on the right side
of his face 2 years ago. The pain was worse in damp weather and was
not related to mastication. 1½ years ago, he felt numbness on right
side of his face. One year ago, his ESR was 92 mm/hour. Right
temporal artery biopsy was normal. Later, he was unable to feel food
inside his right cheek or drink using a straw. He had drooling from
the right side of his mouth. Two months ago, he experienced pain
behind and around the right eye and diplopia on looking towards the
right side. Past medical history includes multiple episodes of right
otitis media and right tympanic membrane rupture. The last episode
of ear infection was 2 ½ years ago. He had double vision 9 years
ago, lasting for a few weeks. He had hypertension for 25 years, DM
Type II for 19 years, CABG 13 years ago and squamous cell carcinoma
of the right pinna 5 years ago. He smoked 2 ½ packs of cigarettes
per day for 33 years and does not drink. His sister has DM and
recurrent temporary diplopia. Physical examination showed an age appropriate, alert, and
oriented male. He weighed 94 Kg. Vitals signs, heart, lungs and
abdominal examination were unremarkable. His pupils were equal and
reactive. His right eye was deviated medially and he was unable to
abduct it. He had impaired touch sensation on the right side of the
face. He also had right facial palsy. His tongue was deviated to the
right. Deep tendon reflexes were absent. He had an old scar from the
right temporal biopsy. Left temporal pulse was normal. CT Scan and
MRI showed moderate cortical atrophy. CBC, ESR, electrolytes and
liver function tests were normal. His BUN 33 mg/dl, and creatinine
was 1.8 mg/dl. This patient initially presented with right sided facial pan and
high ESR. He did not respond to treatment with Prednisone 40mg/day
for one month. Temporal arteritis was ruled out by biopsy. He also
had recurrent diplopia. Later on he developed right 4th,
6th, and 7th nerve palsy. Over time, he also
had right periorbital pain. At this time, more than 2 years after
the initial presentation, it was possible to make the diagnosis of
Tolosa-Hunt Syndrome, which consists of multiple cranial
neuropathies, and painful ophthalmoplegia and has recurring and
remitting course. Early in the disease course, this entity may be
confused with Giant Cell Arteritis. |
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