Facial diplegia as a clinical presentation of a ruptured intracranial dermoid cyst.

Simultaneous facial diplegia, or acute bilateral facial nerve palsy, is an unusual condition. Unlike the unilateral form, facial diplegia is idiopathic in only 20% of cases. Intracranial dermoid cysts are infrequent, and their rupture even rarer; it may occur spontaneously, after cranial trauma, or as a complication of tumour resection. Our case involved a 25-year-old woman with a medical history of gestational diabetes. In December 2009 she experienced skin abscesses in the scapular and perineal regions and was treated with amoxicillin-clavulanic acid. Two months later the patient presented at the hospital with stupor, hypotension, hyperglycaemia (479 mg/dL), metabolic acidosis (venous blood gas analysis: pH 6.87, pCO2 17 mm Hg, pO2 33 mm Hg, bicarbonate 1.6 mmol/L), Kussmaul breathing, and severe dehydration associated with diabetic ketoacidosis, and was therefore admitted to the ICU. Meticillin-sensitive Staphylococcus aureus was isolated in pure culture from purulent exudate from the skin abscesses (the name of the antibiotic was changed from methicillin to meticillin in 2005). After the patient recovered consciousness she exhibited grade V bilateral facial paralysis according to the House-Brackmann Facial Nerve Grading System; all other results from the neurological examination were normal. The results of angiotensin-converting enzyme, serology, autoantibody, and tumour marker tests were all within normal limits. The patient showed positive anti-glutamate decarboxylase and anti-tyrosine phosphatase titres, 13% glycated haemoglobin, and microalbuminuria. A chest radiography, echocardiography, and abdominal ultrasound showed no noteworthy findings. A lumbar puncture disclosed clear cerebrospinal fluid (CSF) with an opening pressure of 12 cm of water, 1 leucocyte/ L, 2 red blood cells/ L, elevated protein levels (115 mg/dL), and hypoglycorrhachia (135 mg/dL in CSF; glycaemia: 406 mg/dL). Gram stain, CSF culture, cryptococcal antigen test, VDRL test, Ziehl-Neelsen stain, and mycobacteria culture yielded negative results. The results of a neurophysiological study (electroneurography, electromyography, and blink reflex test) were compatible with moderate-to-intense axonal damage in the form of decreased amplitude in both facial nerves. Motor and sensory nerve conduction studies of the median, ulnar, and peroneal nerves showed normal conduction velocity and