Cranial Neuropathies With an Unusual Etiology

A 47 year-old-male with a previous diagnosis of multiple sclerosis presented with acute-onset right-sided ptosis for four days. The patient had contracted COVID-19 two weeks prior (diagnosed by RT-PCR), and his symptoms resolved within one week of onset. The following week, however, the patient developed right eyelid drooping and decreased vision bilaterally. Examination was notable for new right cranial nerve III, IV, and V palsies, and a left relative afferent pupillary defect. MRI brain and orbits demonstrated abnormal pachymeningeal enhancement, and enhancement of the cavernous sinus and bilateral optic nerve sheath complexes (with sparing of the optic nerves). Though these findings were found to be present eight year ago, there was noted progression.