(AK) Kaiser Permanente, Honolulu, Honolulu, Hawaii
Subject
Orbital Inflammation; Infection
Description
A 21 year-old Filipino woman had recurrent orbital inflammation for 10 years. She first presented to her pediatrician at age 11 years with intermittent swelling of her right cheek and lower eyelid. CT scan showed soft tissue swelling and sinusitis; MRI showed similar findings. She underwent a biopsy that confirmed chronic sinusitis. For the next two years, her symptoms persisted. An MRI was repeated and showed enlargement of the right medial and inferior rectus muscles with a "tiny rim-enhancing fluid collection along the belly of the medial rectus adjacent to the optic nerve." Given her orbital findings and history of sinusitis, she was referred to rheumatology to assess for granulomatous polyangiits (GPA). It was determined that GPA was unlikely and orbital biopsy was recommended. Three years after initial presentation she underwent a right orbital biopsy that showed only non-granulomatous inflammation. For the next five years she continued to have intermittent flares of subcutaneous nodules on her forehead, scalp, ear, and eyelids that were treated with pulse doses of steroids. She declined repeat biopsy and was transitioned to methotrexate, but she would continue to have flares of orbital inflammation. Ten years after initial presentation, she agreed to repeat orbital biopsy. Pathology showed only "focal patchy inflammation consisting of neutrophils, eosinophils, and lymphocytes." She declined further surgery and continued on methotrexate until April 2018, when she underwent a third orbital biopsy. A larval form consistent on pathologic examination with cysticercosis was extracted from the superonasal orbit, not contiguous with an extraocular muscle. The patient underwent treatment with albendazole and prednisone and had resolution of symptoms.
History
The patient initially presented to me at age 19 years with a 'throbbing, aching pressure' behind her right eye and swelling of the right upper eyelid. Her pain was worse in lateral gaze, although she denied diplopia. She had been prescribed 60mg of prednisone by the referring provider, which reduced the swelling but not the degree of soreness. A review of the chart indicated that she had been having similar symptoms intermittently for eight years. Her visual acuity was 20/15 in the right eye, 20/20 in the left eye. Her pupils were briskly reactive; there was no relative afferent pupillary defect. Color vision was intact in both eyes. She had -1 adduction and abduction deficits in her right eye; her ductions were otherwise full. Exophthalmometry measured the right eye as 2mm more proptotic than the left eye. There was no lid lag in downgaze and no resistance to retropulsion on either eye. The right upper eyelid was 1mm more ptotic than the left. On slit lamp examination she had episcleral and scleral injection laterally on the right eye without chemosis. The remainder of the slit lamp and fundus examinations were unremarkable.
Disease/Diagnosis
Orbital cysticercosis
Date
2019-03
References
None.
Language
eng
Format
video/mp4
Type
Image/MovingImage
Source
2019 North American Neuro-Ophthalmology Society Annual Meeting
