Diplopia as the presenting feature of acute lymphoblastic le
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A 28 year old male presented with acute onset binocular diplopia in the left gaze of 3 days duration. Clinical examination showed orthophoria per corneal light reflex in the primary gaze and esophoria on the alternating cover-uncover test. Prism bar cover test showed 16 prism diopter of esotropia on fixing with the right eye. In the right gaze, it showed orthophoria and 35 prism diopter esotropia in the left gaze. On levoversion there was under the action of the left lateral rectus. On ductions, abduction was restricted in the left eye which was -3 i.e. inability to abduct the eye more than 22.5° past midline and hence the movement of the left eye was approximately 25%. The diplopia chart showed maximum separation of uncrossed images in levoversion. Hess chart showed under the action of the left lateral rectus with overaction of the right medial and also of left medial rectus suggesting of a possible left sixth nerve paresis. His best-corrected visual acuity was 6/6 in both eyes and intraocular pressure on applanation tonometry was 13 mm Hg bilaterally.

On magnetic resonance imaging (MRI), the medial rectus in the left eye appeared bulky with heterogeneity in enhancement and showed mild diffusion restriction. There was also enhancement of multiple cranial nerves namely the right sixth nerve, bilateral 3rd nerves and bilateral trigeminal nerves. Choroid plexus on the left side showed altered signal findings, suggesting a possible immune complex deposition disease. These findings suggested a possible tubercular or inflammatory etiology deposits or immune complex deposition disease. Thus there was left eye abduction deficit with left medial rectus infiltration/enlargement on diffusion-weighted imaging, and enhancement of right sixth cranial nerve. CSF examination revealed elevated protein, decreased glucose, and elevated WBC count with lymphocyte predominance. With these findings, tuberculous meningitis was suspected, as it is endemic in India. However real-time polymerase chain reaction (RT-PCR) for tuberculosis was negative.

A peripheral smear and bone marrow aspiration study was done which showed leukoerythroblastosis, atypical lymphoid cells with round large nuclei, coarse nuclear chromatin, and a moderate amount of basophilic cytoplasm with multiple cytoplasmic vacuoles, suggestive of ALL L3 blasts. On flow cytometry, leukemic cells revealed expression of mature B cell markers like CD19, D20, and CD79a. Dim expression of clonality marker kappa-chain was noted. Findings confirmed mature B cell neoplasm. Fluorescence in situ hybridization test was positive for c-myc rearrangement and karyotype confirmed the translocation t(8:14). The patient was treated with chemotherapy and steroids and his ocular symptoms improved after 2 cycles.

Source: https://www.sciencedirect.com/science/article/pii/S2451993620302462?dgcid=rss_sd_all