Concluded Case

VISION LOSS WITH SEVERE HEADACHE

45yrs old male patient was admitted with B/l Sequential vision loss with severe headache,Provisional diagnosis of ORBITAL APEX SYNDROME was kept according to CT.CSF was sterile, negative for AFB,fungal and malignant cells.Patient was subjecned to DNE under ENT consultation which was negative for any fungal mass,ATT was given and inj MPS was given subsequently meropenem, vancomycin and liposomas Amphotericin B was started suspecting fungal etiology.O/e - Conscious, disoriented,Moving all four extremities,GCS - E2V4M5,Temp - 100°F.DIAGNOSIS AND FURTHER TREATMENT AND MANAGEMENT PLAN??

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Concluded answer

Bilateral visual loss with severe head ache.The provisional diagnosis is orbital apex syndrome.Orbiral apex syndrome is characterised by visual loss due to optic nerve involvement with opththalmoplegia both external and internal.No mentioned about ocular nerve involvement in the available history.When any body is presenting with visual loss with severe headache,the optic fundi exam is the most important clinical findings.The DD of visual impairment with severe head ache the possibilities include BIH,acute hydrocephalus,basal meningitis,optic chiasma parasellar lesion etc.Plain ct brain showed hydrocephalus including dilatation of 3rd ventricle with periventricular hypodensity with periventricular bilateral ischemic lesions.Contrast ct showed contrast enhancing lesion in the sellar and parasellar area with meningeal enhancement ,enhancement of sylvian fissure with sulcal enhancement with hydrocephalus. 4th ventricle looked normal in size.CSf non-contributory.patient received ATT ,broad spectrum antibiotics and antifungal.When ever there is hydrocephalus with meningeal enhancement one has to think the possibility of chronic meningitis with hydrocephalus . The periventricular vascular lesion due to vasculitis.There is parasellar lesion, contrast enhancing which needs further evaluation. Suggest contrast MRI brain as an urgent investigation,to evaluate parasellar lesion.DD include sellar suprasellar lesion vs optochiasmatic arachnoiditis in view of the hydrocephalus. Needs ref to Neurology for proper evaluation .Vasculitis screening including angiotensin converting enzyme to look for sarcoidosis also.Rept CSfstudy after MRI and Neurology evaluation. Needs follow up of this case

All Answers

Bilateral visual loss with severe head ache.The provisional diagnosis is orbital apex syndrome.Orbiral apex syndrome is characterised by visual loss due to optic nerve involvement with opththalmoplegia both external and internal.No mentioned about ocular nerve involvement in the available history.When any body is presenting with visual loss with severe headache,the optic fundi exam is the most important clinical findings.The DD of visual impairment with severe head ache the possibilities include BIH,acute hydrocephalus,basal meningitis,optic chiasma parasellar lesion etc.Plain ct brain showed hydrocephalus including dilatation of 3rd ventricle with periventricular hypodensity with periventricular bilateral ischemic lesions.Contrast ct showed contrast enhancing lesion in the sellar and parasellar area with meningeal enhancement ,enhancement of sylvian fissure with sulcal enhancement with hydrocephalus. 4th ventricle looked normal in size.CSf non-contributory.patient received ATT ,broad spectrum antibiotics and antifungal.When ever there is hydrocephalus with meningeal enhancement one has to think the possibility of chronic meningitis with hydrocephalus . The periventricular vascular lesion due to vasculitis.There is parasellar lesion, contrast enhancing which needs further evaluation. Suggest contrast MRI brain as an urgent investigation,to evaluate parasellar lesion.DD include sellar suprasellar lesion vs optochiasmatic arachnoiditis in view of the hydrocephalus. Needs ref to Neurology for proper evaluation .Vasculitis screening including angiotensin converting enzyme to look for sarcoidosis also.Rept CSfstudy after MRI and Neurology evaluation. Needs follow up of this case

Valuable opinion
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Orbital apex syndrome as per CT, sterile csf, DNE negative for fungus and malignancy Among the causes —-you have ruled out bacterial, fungal infection and malignancy, There is no history of trauma pr sinonasal surgery Vascular— caroto cavernus aneurysm or fistula Now rule out mucocele and ——Inflamatory causes —sarcoidosis,SLE,Churg-Strauss syndrome,Wagner granulomatosis,Tolua Hunt syndrome,Giant cell artritis, orbital inflamatory psuedotumor,andThyroid orbitopathy Look for sings and symptoms look for eye mobility ophthalmoplegia and mydriasis you have not mentioned Investigate for thyroid status T3T4 TSH Vision there is loss of vision is due to optic nerve in volvement that takes weeks or months There is headache but no periorbital facial pain Treatment options are only —- reduction of inflamation by Immunomodulators &corticosteroides NSAIDS and Decompressing surgery to prvide anatomic expansion of the orbit to protet opti nerve in thyroid orbitopathy can be persued

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Get a gad MRI brain with MRS done, there is significant Hydrocephalus, low gcs can be due to it. Place an EVD , if improvement can be considered for shunt. Duration of disease not mentioned. What about Gene xpert for csf and csf culture for AFB.

Valuable opinion
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As from ophalmology Check for visual acuity,RAPD,IOP,OCULAR MOVEMENTS,FUNDUS EXAMINATION is necessary. Look for any mass causing pressure leading optic neuropathy/atrophy. Need neurosurgery opinion regarding decompression if necessary.

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Orbital apex syndrome, I my self consider it diagnosis of exclusion...!! As it is an inflammatory condition, before keeping this diagnosis always rule out infective and structural disease conditions

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NICE ILLUSTRATION THIS IS BELIEVED TO BE DUE TO AUTOIMMUNE PROCESS OR INFLAMMATORY CHANGES OF STRUCTURES PASSING VIA SUPERIOR ORBITAL FISSURE

Orbital apex syndrome

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