Case report A woman with headache and ptosis

A 61-year-old woman presented to the ER with worsening right-sided headaches. She had noticed a painful blister behind her right 3rd molar about a week ago. Chills and rigors associated with myalgias and arthralgias followed. Two days later she developed right-sided headaches, which got worse over the next few days. Vital signs were normal on presentation. Physical examination did not reveal any signs of meningism, respiratory, abdominal or urogenital infection. Her past medical history was significant for a lumbar laminectomy, depression, gastroesophageal reflux disease, hysterectomy and bladder suspension. Her medications included rabeprazole and paroxetine. She did not smoke or drink and denied recreational drug use. Peripheral blood white cell count was 24.2 10/l (4.0–10.0) with neutrophil predominance of 22.2. Hemoglobin was 135 g/l (120.0–160.0), platelets 301 10/l (150.0–400.0), alkaline phosphatase 161U/l (40–135), alanine aminotransferase 34U/l (4–55), aspartate aminotransferase 16U/l (5–35) and albumin 31. ESR was 83mm/h. Urea, creatinine and electrolytes were in the normal range. Intravenous acyclovir and morphine was commenced. Computerized scan (CT) of the head was reported normal. A lumbar puncture revealed red cell count of 9 10 (0–1), white cell count of 16 10 (0–5) with 74% neutrophils, proteins of 0.57 g/l (0.15–0.60) and glucose of 4.0mmol/l (2.7–4.2). Blood cultures grew gram-positive cocci in chains, subsequently identified as alpha-hemolytic Streptococcus. HSV PCR in the CSF came back negative. Acyclovir was discontinued. Ceftriaxone and Vancomycin were commenced. Headaches worsened over the next 2 days and spread to the occipital and left retro-orbital areas and she became photophobic. Five days after her presentation, ptosis of the left eyelid and restricted upward gaze of the eye was noticed. Rest of the neurological examination remained normal. Transesophageal echocardiogram did not show any vegetation and vancomycin was discontinued. The differential diagnosis at this stage was cerebral abscess, cerebral venous thrombosis, Tolosa– Hunt syndrome (THS) and temporal arteritis. Although initial CT scan did not show any evidence of cerebral abscess, it is still a diagnostic consideration in the presence of evolving neurological signs and positive blood cultures. THS is a rare disorder characterized by periorbital or hemicranial pain accompanied by diplopia. The diagnostic criteria for THS includes one or more episodes of unilateral orbital pain persisting for weeks if untreated, paresis of one or more of the third, fourth and/or sixth cranial nerves, demonstration of granulomatous material in the cavernous sinus, superior orbital fissure or orbit by MRI, resolution of pain within 72 h after commencement of corticosteroids and exclusion of other causes by appropriate investigations. Although THS was a strong possibility, other causes needed to be excluded.