| A 34 year old male presents with 5 days of left retro-orbital pain, blurred vision, diplopia and facial pain.
IMAGES TO BE ADDED
Gaze images in right, primary, and left gaze |
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| He had no past medical history, surgical history or regular medications.
He was from Somalia, having emigrated to Australia 3 years prior. He had no alcohol / smoking / recreational drug use history and no recent travel / animal exposures. Examination revealed visual acuity of 6/6 OD, 6/7.5 OS, Ishihara 14/14 OD, 1/14 OS, RAPD OS, normal fundoscopy. Proptosis OS (exophthalmometry 18mm OD, 20mm OS). CN VI palsy OS. Hypoaesthesia L CN V1 / V2. |
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MRI Brain and Orbits with contrast |
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| Impression: Left cavernous sinus and orbital apex syndrome and cervical lymphadenopathy
Infection: TB |
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| Progress: His vision deteriorated to counting fingers on day 3 and he was given pulse methylprednisolone 1g daily for 3 days. |
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| Further Investigations: (abnormal results in red) | ||
| Bloods: Inflammatory markers, HIV/syphilis serology, autoimmune panel: Negative QuantiFERON-TB Gold: Positive Biopsy: |
Imaging: CT chest/abdomen/pelvis with IV contrast – normalFDG PET: Avidity at L orbital apex & R cervical lymph nodes
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Cerebrospinal fluid: 2 red cells, 0 PMNs, 2 lymphocytes Protein 0.34 g/L, glucose 4.7 mmol/L Gram stain & culture: negative AFB smear & TB PCR: negative TB culture: pending |
| The primary differential diagnosis was thought TB related cavernous sinus and orbital apex related syndrome. He was treated with antituberculous therapy (HRZL) and weaning prednisolone.
Visual acuity was 6/6 OU on discharge. At 8 week follow up he was asymptomatic, with a normal neuro-ophthalmic examination. CSF and lymph node TB cultures were negative. |
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| Final Diagnosis: Probable TB of the left orbital apex and cavernous sinus | ||
| Take Home Messages: – Diagnosis suggested by demographics, positive QuantiFERON, histopathology – Negative AFB smear/PCR/culture on LN biopsy not excluding diagnosis – EPTB common ~20% – Orbital apex/cavernous sinus syndrome rare manifestation – Lymphadenitis most common form of EPTB, typically cervical; peak age 30-40 – Primary differential is sarcoidosis, ~10% present with neurological symptoms; usually non-necrotising granulomata – Excisional LN biopsy diagnostic procedure of choice (patient declined) |
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| References: 1. Fontanilla JM, Barnes A, von Reyn CF. Current diagnosis and management of peripheral tuberculous lymphadenitis. Clin Infect Dis. 2011;53(6):555-562. doi:10.1093/cid/cir454 2. Gopalaswamy R, Dusthackeer VNA, Kannayan S, Subbian S. Extrapulmonary Tuberculosis—An Update on the Diagnosis, Treatment and Drug Resistance. Journal of Respiration. 2021; 1(2):141-164. doi:10.3390/jor1020015 3. Bradshaw MJ, Pawate S, Koth LL, Cho TA, Gelfand JM. Neurosarcoidosis: Pathophysiology, Diagnosis, and Treatment. Neurol NeuroimmunolNeuroinflamm. 2021;8(6):e1084. doi:10.1212/NXI.0000000000001084 4. Barreras P, Stern BJ. Clinical features and diagnosis of neurosarcoidosis – review article. J Neuroimmunol. 2022;368:577871. doi:10.1016/j.jneuroim.2022.577871 |
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