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1999 Resident Poster Competition

Muhammad Hussain M.D.
Univ. of Missouri--Columbia
Tolosa-Hunt Syndrome Mimicking Temporal Arteritis

Muhammad Hussain M.D.: Tolosa-Hunt Syndrome Mimicking Temporal Arteritis

A 72 year old caucasian male had onset of pain on the right side of his face 2 years ago. The pain was worse in damp weather and was not related to mastication. 11/2 years ago, he felt numbness on right side of his face. One year ago, his ESR was 92 mm/hour. Right temporal artery biopsy was normal. Later, he was unable to feel food inside his right cheek or drink using a straw. He had drooling from the right side of his mouth. Two months ago, he experienced pain behind and around the right eye and diplopia on looking towards the right side. Past medical history includes multiple episodes of right otitis media and right tympanic membrane rupture. The last episode of ear infection was 2 1/2 years ago. He had double vision 9 years ago, lasting for a few weeks. He had hypertension for 25 years, DM Type II for 19 years, CABG 13 years ago and squamous cell carcinoma of the right pinna 5 years ago. He smoked 2 1/2 packs of cigarettes per day for 33 years and does not drink. His sister has DM and recurrent temporary diplopia.

Physical examination showed an age appropriate, alert, and oriented male. He weighed 94 Kg. Vitals signs, heart, lungs and abdominal examination were unremarkable. His pupils were equal and reactive. His right eye was deviated medially and he was unable to abduct it. He had impaired touch sensation on the right side of the face. He also had right facial palsy. His tongue was deviated to the right. Deep tendon reflexes were absent. He had an old scar from the right temporal biopsy. Left temporal pulse was normal. CT Scan and MRI showed moderate cortical atrophy. CBC, ESR, electrolytes and liver function tests were normal. His BUN 33 mg/dl, and creatinine was 1.8 mg/dl.

This patient initially presented with right sided facial pan and high ESR. He did not respond to treatment with Prednisone 40mg/day for one month. Temporal arteritis was ruled out by biopsy. He also had recurrent diplopia. Later on he developed right 4th, 6th, and 7th nerve palsy. Over time, he also had right periorbital pain. At this time, more than 2 years after the initial presentation, it was possible to make the diagnosis of Tolosa-Hunt Syndrome, which consists of multiple cranial neuropathies, and painful ophthalmoplegia and has recurring and remitting course. Early in the disease course, this entity may be confused with Giant Cell Arteritis.

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