Korean J Ophthalmol.  2008 Sep;22(3):201-204. 10.3341/kjo.2008.22.3.201.

A Case of Oculomotor Nerve Palsy and Choroidal Tuberculous Granuloma Associated with Tuberculous Meningoencephalitis

• Moon S
• Son J
• Chang W

• KMID: 1070760
• DOI: http://doi.org/10.3341/kjo.2008.22.3.201

Abstract

We report a rare case of oculomotor nerve palsy and choroidal tuberculous granuloma associated with tuberculous meningoencephalitis. A 15-year-old male visited our hospital for an acute drop of the left eyelid and diplopia. He has been on anti-tuberculous drugs (isoniazid, rifampin) for 1 year for his tuberculous encephalitis. A neurological examination revealed a conscious clear patient with isolated left oculomotor nerve palsy, which manifested as ptosis, and a fundus examination revealed choroidal tuberculoma. Other anti-tuberculous drugs (pyrazinamide, ethambutol) and a steroid (dexamethasone) were added. After 3 months on this medication, ptosis of the left upper eyelid improved and the choroidal tuberculoma decreasedin size, but a right homonymous visual field defect remained. When a patient with tuberculous meningitis presents with abrupt onset oculomotor nerve palsy, rapid re-diagnosis should be undertaken and proper treatment initiated, because the prognosis is critically dependent on the timing of adequate treatment.

Keyword

Choroidal tuberculous granuloma; Oculomotor nerve palsy; Ptosis; Tuberculous meningoen-cephalitis

MeSH Terms

Adolescent
Antitubercular Agents/therapeutic use
Blepharoptosis/diagnosis/drug therapy/microbiology
Choroid Diseases/diagnosis/drug therapy/*microbiology
Dexamethasone/therapeutic use
Drug Therapy, Combination
Ethambutol/therapeutic use
Glucocorticoids/therapeutic use
Humans
Magnetic Resonance Imaging
Male
Meningoencephalitis/diagnosis/drug therapy/*microbiology
Mycobacterium tuberculosis/*isolation & purification
Oculomotor Nerve Diseases/diagnosis/drug therapy/*microbiology
Perimetry
Pyrazinamide/therapeutic use
Radiography, Thoracic
Tuberculoma/diagnosis/drug therapy/*microbiology
Tuberculosis, Meningeal/diagnosis/drug therapy/*microbiology
Tuberculosis, Ocular/diagnosis/drug therapy/microbiology
Visual Fields

Figure

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  Fig. 1 Chest X-ray taken at initial presentation (a year before eyelid drooping developed). Diffuse effusion with pleural thickening was observed in the left side.

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  Fig. 2 Brain MRI (a) At initial presentation, This image shows strong enhancement of leptomeninges at the basal cistern and multiple tuberculous granuloma at the brain base. (b) The size and number of the tuberculous granuloma had increased at second presentation.

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  Fig. 3 Fundus photograph of the right eye (a) A solitary yellowish choroidal granuloma was noted in the right eye at initial presentation. (b) The choroidal tuberculoma had decreased and scar formation was observed in the right eyeafter three months of added treatment.

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  Fig. 4 Nine cardinal movements of eyeballs (a) Upper lid dropping and up gaze limitation was noted in the left eye at second presentation. (b) Upper lid dropping and up gaze limitation were much improved in the left eye after 3 months of treatment supplementation.

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  Fig. 5 Visual field test. A right homonymous upper quadrant defect was noted after four months of added treatment.

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