Naureen Farook Sam Tirgari Jacqueline Pflaum-Carson
Henry Ford Health System
A 27-year old female with no past medical history presented to the ED multiple times with intractable headaches and blurry vision. Her symptoms involved a right-sided throbbing pain for 6 weeks with r..
A 27-year old female with no past medical history presented to the ED multiple times with intractable headaches and blurry vision. Her symptoms involved a right-sided throbbing pain for 6 weeks with recent onset of progressively worsening blurry vision with increasing right eye pressure. She had multiple ER visits, PCP appointments, as well as ophthalmology and neurology evaluations. Her CT and MRI images did not reveal any abnormalities initially, and she was repeatedly symptomatically treated with migraine cocktails, magnesium, as well as solumedrol during her ED visits. However, after 6 weeks of ongoing symptoms, an MRV demonstrated soft tissue thickening of the right cavernous sinus and anterior Meckel's Cave, with extension into the foramen rotundum, right proptosis with increased edema and enhancement of the right superior and lateral rectus muscles with edema of the right lacrimal gland. Lumbar puncture revealed 39 WBCs, 95% lymphocytes, normal protein and glucose. HCV, VZV, CMV, EBV, bacterial and fungal CSF cultures were negative. ANA, DNA, ENA, ANCA, Sjogren's antibodies,serum and CSF ACE, lyme antibodies, CSF cytology and flow cytometry, serum and CSF IgG subclasses were negative. Her symptoms were controlled with IV methylprednisolone 250mg Q6 while inpatient. Ophthalmology performed a right anterior orbitotomy with lacrimal gland biopsy, which demonstrated a possible vasculitic process with lymphocytic perivascular inflammation. She achieved good symptom control with prednisone. Based on her clinical presentation, imaging, and biopsy results, she was diagnosed with Tolosa-Hunt syndrome. This case report emphasizes the recognition of a common chief complaint due to a rare, inflammatory disorder. In the ED setting, steroids may provide the best diagnostic clue for a patient with multiple previous visits for intractable headaches as well as presence of concurrent periorbital inflammation.