A Case Of Total Ophthalmoplegia Associated With A Covid-19 Infection: Case Report
Hajjar, D., Sultan, D., Khalaf, A., Hesso, H., & Kayyali, A. (2022). A case of total ophthalmoplegia associated with a COVID-19 infection: case report. Oxford medical case reports, 2022(5), omac050. https://doi.org/10.1093/omcr/omac050
View Original Source →Abstract
We are presenting a rare case of an acute complete external ophthalmoplegia with positive polymerase chain reaction (PCR) for SARS-CoV-2. Our case is the first case that depicts development of Tolosa-Hunt Syndrome (THS) following infection with COVID-19, with a challenging diagnosis and spontaneous improvement. A 65-year-old diabetic female presented with a complete external ophthalmopegia in the left eye and a severe left-sided headache. The PCR result for SARS-CoV-2 was positive. Brain and orbital computed tomography scan and magnetic resonance imaging were both unremarkable. We diagnosed the case as THS after ruling out other differential diagnoses. The patient refused to receive prednisone, so we had to observe her closely for 6 months during which period we recorded a spontaneous recovery. Acute ophthalmoplegia is a very challenging presentation. It needs full workup to exclude the wide range of differential diagnoses.
Case Details
Disease Location
Left eye
Personal Characteristics
65-year-old caucasian female, uncontrolled diabetes mellitus
Clinical Characteristics
Left periocular pain, droopy eyelid and left ocular movement limitation for a period of 4 days. Two weeks before admission, she had had a severe left-sided headache unresponsive to sedatives, along with fatigue, dry cough and fever. Physical examination: complete external ophthalmoplegia on the left eye and total left ptosis with a mild chemosis. The pupil was semi-dilated and nonreactive to light. Left corneal hypoesthesia appeared 2 days after admission, which was consistent with an injury in the first branch of the fifth cranial nerve. Polymerase chain reaction for covid-19 was positive. Crp was elevated. The diagnosis of tolosa-hunt syndrome (ths) was made after the exclusion of other pathologies.
Remission Characteristics
On follow-up, her ocular symptoms and signs started to improve spontaneously 3 months after admission. A regression in the ptosis, a partial recovery in the third and fourth cranial nerves were detected. She could adduct, elevate and depress the left eye into primary and adduction positions. By the end of the 6-month period, all the involved nerve functions were restored except for the sixth nerve and the patient ended up with exotropia.
Treatment & Mechanisms
Proposed Remission Mechanisms
Sars-cov-2 virus may have triggered an immunological reaction leading to the development of the ophthalmoplegia, which we believe is ths.