A 48 year old woman presented to her ophthalmologist with complaints of headache and double vision. She first noticed diplopia two months prior to evaluation, which waxed and waned in intensity. One month later, she had recurrent severe diplopia, most prominent on rightward gaze, accompanied by nausea, headache, and photophobia. Her symptoms persisted and progressed to include and right-sided eyelid heaviness. The patient was previously healthy, born in New York City, and had worked in maintenance.
Neurologic exam revealed right ptosis, sluggish pupil, lateral gaze palsy, and diminished medial as well as downward gaze. She also had hypoesthesia in the V2 distribution. The patient was afebrile and had no meningeal signs. She had no pulmonary symptoms.
Results of complete blood count, routine chemistry, complement testing, and serum ACE were normal. Sedimentation rate was elevated at 49. MRI of the brain was performed, showing an enhancing lesion in the right cavernous sinus (Fig. 1). A Quantiferon -GOLD test was performed as part of the initial work-up, and returned positive (Nil 0.046, TB Ag > 10, Mitogen > 10, TB-Nil > 10).
Result of chest X-ray and HIV testing were negative. 18-FDG PET-CT was performed to assess for additional disease sites that would be more amenable to biopsy. PET-CT cuts in the chest revealed a subcarinal mass with intense uptake (SUV of 11). Biopsy of the subcarinal lymph node was performed using a robotic VATS procedure. Lymph node pathology revealed both necrotizing and non-necrotizing granulomas, and cultures subsequently grew M. tuberculosis, susceptible to all first-line drugs. The patient was started on therapy with INH 300 mg daily, rifampin 600 mg daily, pyrazinamide 1500 mg daily, and levofloxacin 750 mg daily. Ethambutol was not given because of concern for potential ocular toxicity, given her cranial nerve deficits and diplopia. She was also treated with daily prednisone. Pyrazinamide was discontinued in 3 months, and levofloxacin in four months. She was treated with INH and rifampin to complete a 12 month course.
The patient's gaze palsies improved while on therapy, though her facial hypoesthesia persisted. Repeat MRI 3 months into treatment showed improvement of cavernous sinus lesion. MRI after treatment showed near-complete resolution of the lesion (Fig. 2).