Isolated Oculomotor Nerve Palsy – A Rare Initial Manifestati
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Tuberculous meningitis is common infection of the central nervous system particularly in developing countries like India where Tuberculosis is so rampant. Early diagnosis and treatment are very vital key factors as any delay in management can be potentially hazardous in the form of neurological sequelae and even death. This disease entity has very variable modes of presentation ranging from simple headache to frank altered sensorium. Isolated oculomotor nerve palsy is such a rare presentation of tuberculous meningitis. This uncommon presentation should be kept in mind whenever such case is encountered by clinicians.

A 20 year old female came to our hospital with gradual onset progressive drooping of eyelid of the left eye for last 20 days. She also complained of binocular diplopia. She observed that diplopia increased on right gaze. She did not have headache, fever, nausea, vomiting, seizure, altered sensorium and orbital pain. Her vitals were normal. Neurological examination of the patient revealed presence of isolated left third nerve palsy (ptosis, pupillary dilatation, absence of light reflex, loss of extra ocular movements attributed to third cranial nerve). Rest of the examination was within normal limit.

Routine laboratory investigations, thyroid function tests, C-reactive protein and Anti-nuclear antibodies were within normal range. MRI brain revealed slight ventriculomegaly.

Lumbar puncture was performed because of presence of this slight ventriculomegaly. Examination of cerebrospinal fluid (CSF) showed cell count of 104/mm3 (lymphocytes 78%, neutrophils 18%, monocytes 4%), protein 115 mg/dl and sugar level of 30 mg/dl. Gram negative and Zeihl Neelsen staining for Acid fast bacilli were negative. Polymerase chain reaction for tuberculosis came to be positive.

Based on the above mentioned CSF findings, patient was put on anti tubercular therapy (rifampicin, isoniazid, ethambutol and pyrazinamide) in appropriate doses. Adjunctive steroid was also given in standard dose. After two weeks of therapy ptosis improved. A second CSF study was performed on 21st day of therapy which revealed improvement in parameters.

Whenever a case of an isolated oculomotor nerve palsy is encountered, a careful search for the common causes should be sought which include brain stem infarct, multiple sclerosis, tumours, aneurysms, cerebral herniation, cavernous sinus thrombosis, carotid cavernous fistula, diabetes mellitus, Tolosa hunt syndrome, myasthenia gravis etc. However detailed history, neurological examination and relevant neuroimaging studies can exclude most of them.

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