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Show /. Clill. NCllrt1-,lplltlltl/ll1(l1. 5: :!7-:!ll, IllH5. Cryptic Disseminated Tuberculosis Presenting as Gaze Palsy T\tARIO L. R. MONTEIRO, M.n.~ JAMES R. COPPETO, M.D. Abstract We present a case of gaze palsy caused by a pontine tuberculoma associated wih cryptic disseminated tuberculosis. The only symptoms in this patient were those caused by her gaze abnormality despite the presence of disseminated tuberculosis that was later confirmed at autopsy. Introduction Paral\'sis l)i hllriwntal gaze is generally produ..: ed b\' lesions In the plmtine tegmentum. In mllst ..:ases, the diagnosis depends on extensive neurl'radi'llogic ,'n..:ologic and infectious disease im·estigations. sin..:e dire..:t biopsy oi the lesion is usually nllt ieasible. \\'e . des..:ribe a patient with horizontal gaze palsy and cryptic disseminated tuberculosis. A tuberculoma oi the pontine tegmentum was demonstrated at autopsy. Interestingly, the diagnosis oi tuberculosis in this patient was obtained only after biopsy of a uterine-cervix lesion was periormed, despite disseminated involvement with the disease Case Report A 56-year-old previously healthy woman was referred for neuro-ophthalmic evaluation in Jum.' 1982, because of a 3-month history of double vision. Examination revealed absent abduction of the left eye and a supranuclear paralysis of left gaze characterized by inability to perform saccadic or pursuit eye movements to the left, yet preserved oculocephalic-induced movement of the right eye toward the left The remainder of the ophthalmic and neurologic l'xJminations W,1S normal. A VDRL, FTA-ABS, and JntinucleJr antibody were negative. A Westergren erythrucytl' From the Department of Ophthalmolo~y. Unlv,'"ity of Con· nectlcut Health Center, Farmln~ton, C"nnl'l'lll'ul; .mJ St. Mary's MedICal Center, Waterbury, Conn,'etJeul • Pr~sent address: Department of Ophth"lmolo~y, I ""pit••1 das Clinicas. University uf Sao Paulo M"di".ll S,hool, S.io Paulo, Brazil. March 1985 sedinwnt,1tion ralL' was 00 mm/hour; a temporal .HlL'ry biopsy W,lS negative. Shortly .liter the administration of renografin during a cranial CT scan she suffered a grand mal seizure and was admitted to the hospital. Contrast enhanced CT scan showed multiple small hyperdense lesions throughout both cerebral hemispheres and a large one in the area of the pons, near the fourth ventricle (Fig. 1). General phYSical examination was normal. Neurologic examination revealed her eye movement abnormalities to be unchanged and also a slight left facial weakness. Abnormal laboratory findings included alkaline phosphatase of 208 units, lactic dehydrogenase of 264 units, and an angiotensin-converting enzyme level oi 43 units (normal less than 31 units). Lumbar puncture revealed clear and colorless ..:erebrospinal fluid under normal pressure. GluLllse, Gram stain, a..:id-fast stain, cytology, India ink preparation, and bacterial and iungal ..:ulture of the ..:erebrospinal fluid were normal or negative. The following investigations also gave normal results: skin testing with 5 units oi purified protein derivative, blLlOd and urine cultures, thyroid function tests, chest x-ray, whole chest tomography, liver-spleen s..:an, mammography, intravenous pyelographY, colLmoscopv, barium enema, upper gastral inlt.'stinal endl'scop\' and radil'graphv with barium. bone sc,mning, peh'ic ultrasound, ,1nd CT sc,1I1ning of Ihl.' pelVis and kidneys. The presumpti\'l> di,1gl1l'sis was intr.1Crani.11 metastati..: neoplasia fwm an llccult primar\·. Three weeks later she had a seizure. Hl.'r temperature was 1020 F. A new neuwlL,gic finding was a slight leitw.ud sw,1\' whill' walJ..ing. Labllratory investigatilll1s \\It'rl' unch,lnged e,cl.'pt for a whill' bluud cell cuunt of 2,500 ct>Il/..:u.1 with 115";, segmented pulyn1llrphonude,H kUcll..:ytes ,md 25";, Ivmphucvtes. Gynecologic e',lmination. periurnwd as part ui sl',H..:h iur systemic malign, mc\', disdosed .1 minule slightly l':>.oplwtic and ulcerated lesiun of thl' cervix. A bil'psy oi this lesion n'Yl',lkd granull,mas with acid-fast bacteria. A subsequent livl>r biopsy showed similar findings. The p,ltient eventually received rifampin. 27 dh,lIllbllt,)1, and is\lI1i,lIid without clinical impwvenwnt. Otlwr ,lntitllberculosis medications <lS I\'ell ,)S corticostt'roids were instituted, but could not pn'vl'nl slol\' dl'tl'rior,ltion ,wd death in Febrll, HY IllHJ. figure I. C"ntrdst enhanced CT sC,1n shllwin~ n"dul." Ie",'n 1f1 tht-' ..lrl',) (If the pons. Autopsy revealed many small caseating granulomas in the liver, kidneys, adrenal glands, and right ovary; and a single O.3-cm pulmonary nodule of the left upper lobe. Central nervous system examinatiun revealed multiple small supratentorial caseating granulomas in various stages of necrosis, and a large and necrotic tuberculoma in the left pontine tegmentum (Fig. 2). Discussion Tuberculosis is still a serious health problem in this cuuntry, despite the steady decline in the incidence of its pulmonary form. In fact, the number of cases uf extrapulmonary tuberculosis, including the miliary form of the disease, has remained relatively constant. I Miliary tuberculosis in children usually results from the acute hematogenous dissemination of a recently acquired infection whereas in adults it generally arises from foci of previous infection which reactivate, undergo necrosis, and seed the circulation. Clinical findings include high fever, chills, night sweats, and prostration, and chest xray reveals the classic milian' involvement of the lungs.~ . Over the last three decades, there has been a change in the pattern of milian' tuberculosis. A progressive decline in the numb'er of cases of the classical fulminant form of the disease has occurred while there has been the emergence of an insidious form in adulthood.'· This form has been called cryptic dissemina ted tu berculosis." Although it can cause malaise, weight loss, anergy, and km'-grade fever, it lacks the classic 28 nI'l [ TIlT[ITITfT1 234 DA ; fi~ure 2. I r""w,,,,<, '<'d',," ,,' 111<' P""s slll'wlI1h tU!:><'fCUI,'m.l III th., left tt'~mt'ntum. Journal of Clinical Neuro-ophthalmology fulminant symptomatology of classic miliary tuberculosis." Our patient illustr,lks tilt' difficulties in di,lgnosing this conditil1l1. The llnly clinic,ll findings were pn)duced by her pontinl: tubnculolll,l despite dissemin,lted inHllvenlt'nt bv the disease. There W,lS also 1111 pl'rSl1l1,11 or Lllllilv history of tubercull)sis; ,lnd chest ,-r,1\', wholl' chesttolllograpl1\' , and PPD skin kst g:lH' norlll,ll findings. Centr,ll ner\'l)US syskm tuberculolll,lS genl'rallv represent Il)ng-st,Hiding intr,lCr,lIli,ll infl'ction:~ but m,1\' ,llsl) be prt'Sl'nt in the Clllltl',t of cI,lssic miliary tu bt'rL-ulllsis' lIu r p,l tien t illustr,ltL's th,lt it C,lIl ,1IsL) bt' ,15SL)ci,1tl'd with the crvptic form of llliliary tubt'rctIiLlsis. Altl1l1ugh relatiyt'lv silt'nt, this fllrlll ,llsl) c,uril's ,1 5erillus prognosis. Therefl) re. ,1 high inde, llf suspicion is necessary for early di,lplL)sis. Intt'restinglY, in l)ur patient, the di,lp1l1sis W,15 made thwugh bil)psy of ,1 uterine cervi, lesll)n. This lesil1l1 W,lS Cl)mplt'tt'1y asymptL) matlc gYnecl)logic e,amin,ltion was performed l)nly bec,luse l)f sYstema ~ic search for possible malign,lnCY In rt'twspecl, the presence of an eleyated erythrL) C\·te sedimentatiL1I1 rate ,1Ild hepatic enzymes abnL)rmalities cl)mpatible with micwbiliary obstructiL1I1 shL)uld ha\'e pwmpted initial liver biL) PSY This case also had the unusual finding of an ele\ated angiotensin converting enzyme level. .-\1 thL)ugh ini tia I in vestiga tions suggested tha t ele\ atwn L)f this enzyme might be used as a marker fL)r sarcoidusis, subsequent reports showed similar findings in uther conditions including leprosy, Gaucher's disease, histoplasmosis, coccidioidom\' cosis, cryptococcosis, and pulmonary tuber- March 1985 Monteiro, Coppeto culosis." II Extrapulmunary disseminated tubernIiosis should be ,1dded in this list, as exemplified by this case. References I. F.Hl'r. I.S, Lowl'll, AM., and Ml'ador, M.P.: Extrapulmon, HV tuIwrculosis In thl' Unilt'd States. Alii. I 11'111<'1111,,1. 109: 20e; 17, 1979. 2 I'n'z., R.D.: Extr,)pulmollary tuberculosis. In C<,cll In II,,,,," "I M<,dirill<' (lhth l'd.), jB. Wyngaar and 1..11 Smdh, Ir., Eds. William B. Saunders, J'hiladl ·lphi,). 1982, Pl'. 1548-1554. J Edltori,ll: Mili.HV tubl'rculosis: /\ changing pattern. LIIII,<'I 1: 41'5-486, 1970. 4 Bobrowitz, I.D.: /\ctiVl' tuberculusis undiagnused until ,JUtopsv. AliI f. M<,d. 72: 650-658,1982. 5 CHlson, R.E.: Cryptic dlssemmated tuberculusls. f.AMA 245: 2344, 1981. h. Proudfoot, AT, Akhtar, A.j, Douglas, Ae., and flurne, N.W.: Miliary tubercuiusis m adults. Br. M<,d. f. 2: 273-276,1969. 7. Mayers, MM, Kaufman, D.M, and Miller, M.Ho' Rl'cent cases of intracranial tuberculumas Ne/lrol" Sl/28: 256-260,1978. H. Witham, R.R .. Johnson, R.H, and Roberts, D.L Diagnosis of miliary tuberculosis by cerebral computerized tomography. Ardl. IlIlcm' Med. 139: 47941' 0, 1979. 9 Romer, F.Ko' Angiotensin-converting enzyme in sarcLlldosls Acta Med. Scalld. 206: 27-30,1979. 10. Schultz. T, Miller, We., and Bedrossian, e.W.M .. Clinical application of measurement of angiotensin- converting enzvme level. f.AMA 242: 439441, 1979. 11. Rvder, KW.. jay, Sj. Kiblawi, SO. and Hull. M.T.: Serum angiotensin converting enzvme acti\'ity in patients with histoplasmosis. f.AM.A 249: 1888-1889,191'3. 29 |
