Midbrain tuberculoma presenting as partial ptosis.

To cite: Kumar S, Shukla R. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2014-207686 DESCRIPTION A 14-year-old boy presented with mild headache of 20 days duration and three episodes of vomiting over the past 3 days. On clinical evaluation, he had grade I papilloedema along with bilateral partial ptosis (figure 1). Extraocular movements, pupils and the rest of the neurological examination were normal. MRI of the brain showed a thick-walled ring-enhancing lesion with perilesional gross oedema causing obstructive hydrocephalus due to the obstruction of the aqueduct sylvius (figure 2). A magnetisation transfer (MT) image showed brighter than T1-weighted (T1W) contrast image, which favoured the diagnosis of tuberculoma. The patient showed improvement on antituberculous and dexamethasone therapy. Isolated oculomotor nuclear involvement is an uncommon phenomenon. Isolated bilateral ptosis is a rare presentation, because it is usually associated with superior rectus palsy. The subnucleus of the superior rectus and levator palpebrae superioris lie in proximity. Therefore, ptosis due to nuclear lesion is usually associated with upgaze palsy. Isolated bilateral ptosis with sparing of the extraocular muscles and pupils has been described due to mesencephalic lesions. Isolated bilateral ptosis without hemiplaegia has also been reported in midbrain haemorrhage. Cellular components of lesions show hyperintensity on T1W MT images, which further enhance on contrast.