Page 29 - Delaware Medical Journal - May/June 2020
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ABSTRACTS
manifestations, including otitis media, hearing loss, and vertigo. For many patients, and those cited in case reports, symptoms to appear. As an important and potentially early marker of disease, it is important to consider granulomatosis with polyangiitis in patients with otologic pathologies that are refractory to conventional treatments.
CONTRIBUTOR
■ Blake Shoemaker is a fourth-year medical student at the Philadelphia College of Osteopathic Medicine and a Branch Campus student at ChristianaCare.
References:
Hochberg, M. C., Gravallese, E. M., Silman, A. J., Smolen, J. S., Weinblatt, M. E., & Weisman, M. H. (2019). Rheumatology. [electronic resource]. Elsevier. Retrieved from https://search-ebscohost-com. ezproxy.pcom.edu/login.aspx?direct=true& db=cat00201a&AN=pcom.51600&site=e ds-live&scope=site.
Safavi Naini A, Ghorbani J, Montazer
Lotfe Elahi S, Beigomi M. Otologic Manifestations and Progression in
Patients with Wegener’s Granulomatosis:
A Survey in 55 Patients. Iranian Journal Of Otorhinolaryngology. 2017;29(95):327-331.
Santos F, Salviz M, Domond H, Nadol
JB. Otopathology of Vasculitis in Granulomatosis With Polyangitis. Otology & Neurotology. 2015;36(10):1657-1662. doi:10.1097/MAO.0000000000000868.
Costa CF da, Polanski JF. Wegener Granulomatosis: Otologic Manifestation as First Symptom. International Archives Of Otorhinolaryngology. 2015;19(3):266-268. doi:10.1055/s-0034-1387164.
Abstract 2nd Place
A Rare Cause of Painful Ophthalmoplegia: Tolosa-Hunt Syndrome by Devin Sullivan, MSc, PCOM, MS4
Co-Authors: Justin Nichols, MD, PGY2; Chelsea Hastry, MD, PGY2; Ajeetpal Hans, MD; Kevin Patel, MD
Introduction: Tolosa-Hunt syndrome (THS) 65 years, with an annual incidence of one case per million per year worldwide. It is a within the cavernous sinus or superior nerves III, IV, V1, and VI, causing painful ophthalmoplegia. This idiopathic and relapsing syndrome has no known triggers or geographic, gender, or racial predominance. As a diagnosis of exclusion, THS requires a comprehensive work-up.
Case Description: A 42-year-old woman presented with the chief complaint of sudden- onset, constant, 10/10, stabbing, and left-sided symptoms were headache, blurred vision, diplopia, photophobia, lacrimation, facial
left eye. Her medical history included migraine, obesity, asthma, diverticulitis,
and osteoarthritis; home medications were Lortab, olanzapine, and rizatriptan, which did not relieve her headache. She was afebrile and hemodynamically stable throughout
her hospital course. Left eye examination revealed a dilated pupil slowly reactive to light, ptosis, diminished vertical gaze, medial deviation, decreased visual acuity, and for mild neutrophilia. ACE receptor antibody, ANA multiplex, and ANCA studies were negative. RPR was non-reactive. Blood cultures were negative. CSF studies, including Lyme disease, were unremarkable. Chest x-ray, CT scan, MRA, and MRV were unrevealing. However, MRI with contrast showed abnormal enhancement on the left lateral wall of the cavernous sinus. Two
days of broad-spectrum IV antibiotics were
completed without improvement. The patient was switched to steroids and within one day had considerable pain relief. Her negative workup, suggestive imaging, and response to
Discussion: The differential for painful ophthalmoplegia is broad and includes traumatic, infectious, neoplastic, vascular, including THS. Appropriate hematologic tests, CSF studies, and neuroimaging must be completed. MRI is reported to be the most sensitive imaging study for THS. meningioma, or sarcoidosis. Therefore, it is critical to maintain a high suspicion for these alternative diagnoses throughout the clinical course and during follow-up. Symptoms typically resolve without treatment within eight weeks. Steroids are known to provide rapid resolution within 72 hours. There is
no evidence that steroid treatment prevents relapses or the rare complication of residual nerve palsy. Several case reports recommend a follow-up MRI every one to two months for two years. Each relapse must be approached as a new diagnosis with a full work-up and repeat imaging. This clinical framework for the diagnosis, treatment, and follow-up of THS is essential in order to optimize clinical outcomes.
CONTRIBUTOR
■ DevinM.Sullivan,MScisafourth-yearmedical student at the Philadelphia College of Osteopathic Medicine. She is a DIMER student and part of the ChristianaCare Branch Campus.
References:
Amrutkar, C; Burton, EV. Tolosa-Hunt Syndrome. StatPearls. StatPearls Publishing LLC, 2019. https://www.ncbi.nlm.nih.gov/ books/NBK459225/. Accessed April 15, 2019. Shindler, KS MD.
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