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Show /. Clin. Neuro-ophthalmol. 3: 127-130, 1983. Bilateral Internuclear Ophthalmoplegia in Carcinomatous Meningitis C. STEPHEN FORD, MD. JULIA CRUZ, MD. JOSE BILLER, MD. WAYNE LASTER, MD. DOUGLAS R. WHITE, MD. Abstract A 53-year-old man with oat cell carcinoma of the lung developed a bilateral internuclear ophthalmoplegia in association with carcinomatous meningitis. While bilateral internuclear ophthalmoplegia has been described in one case of cryptococcal meningitis, this is the first reported case occurring in association with carcinomatous meningitis. Bilateral internuclear ophthalmoplegia results from bilateral lesions of the medial longitudinal fasciculus causing interruption of the internuclear message carried by the medial longitudinal fasciculus between the abducens nucleus and the medial rectus subnucleus. While bilateral internuclear ophthalmoplegia is highly suggestive of demyelinating disease, many other causes have been defined in recent years. We report a case of bilateral internuclear ophthalmoplegia occurring in association with carcinomatous meningitis. To our knowledge, this is the first such case reported. Case Report A 53-year-old man presented in May 1979 with obstructive pneumonitis secondary to a right upper lobe mass. Diagnosis of oat cell carcinoma was made by cytology of bronchial washings and histology of the ipsilateral supraclavicular node. Metastatic evaluation with liver scan, bone scan, bone marrow biopsy, and computed tomography of the head with infusion of contrast agent revealed From the Departments of Neurology (CSF), Hematology/Oncology (JC, DRW). and Radiology (WL) of the Bowman Gray School of Medicine, Wake Forest University. Winston-Salem. North Carolina; and the Department of Neurology (JB) of the Stritch School of Medicine. Loyola University. Maywood. Illinois. June 1983 no evidence of extrathoracic involvement. The patient was treated with radiation therapy to the lung mass and the supraclavicular areas (3,000 rads) and prophylactic whole brain irradiation (3,000 rads). Chemotherapy consisted of Cytoxan, Adriamycin, Vincristine, Methotrexate, and CCNU from May 1979 until July 1980. The patient did well with increasing activity, increasing weight, and resolution of his obstructive pneumonitis. In August 1980, the patient developed progressive weakness and paresthesias in his lower extremities. A panmyelogram revealed multiple lumbar intradural nodules. Spinal fluid revealed an elevated protein of 640 mg/dl and cytology demonstrated neoplastic cells. Chest x-ray remained stable. No evidence of metastatic disease was noted on repeat computerized tomographic head scan or bone scan; however, a 3 X 5 cm indurated mass deep to the sternal insertion of the right sternocleidomastoid muscle was felt to be consistent with lymph node metastasis. The patient was treated with radiation therapy to the lumbosacral spine and his chemotherapy was changed to VP-16. His leg symptoms markedly improved. The neck mass progressed subsequently, but then completely resolved after local irradiation in November 1980. In November 1981, the patient sustained a fracture of the left femur following a fall in which he suffered no head trauma. There was no evidence of metastatic disease by femur x-rays, bone scan, or chest x-ray. Physical examination revealed skew deviation with the right eye higher than the left and gaze-evoked vertical nystagmus. On lateral gaze in either direction, there was paresis of the adducting eye and variable horizontal jerk nystagmus in the abducting eye (Fig. 1). Convergence was relatively intact. The remainder of the neurologic examination was unremarkable. Intravenous edrophonium chloride (Tensilon 10 mg) did not alter the patient's ophthalmoplegia. Repeat computerized tomographic head scan (Fig. 2) showed cerebral and cerebellar atrophy as well as multiple, 127 INO in Meningitis B Figure 1. p.. tient's eyes during m..xim..1 right (A) .. nd left (8) lateral gaze. Figure 2. (A) Postinfusion sc..n demonstr.. tes tumor infiltration of the mesenceph.. lon. (8) Postinfusion sc..n through the !.>ter.. l ventricles reveals 5ubependym.. l metast..ses. irregular, enhancing densities encasing the lateral and third ventricles, consistent with subependymal metastases. The patient received a second course of high-dose intravenous Methotrexate therapy. His internuclear ophthalmoplegia persisted but no new focal neurologic deficits developed. He died in July 1982. An autopsy was not performed. 128 Discussion Bilateral internuclear ophthalmoplegia is usually seen in demyelinating disease. Cogan felt that bilateral internuclear ophthalmoplegia may be frequent with other types of brain stem lesions; however, except for multiple sclerosis, which affects Journal of Clinical Neuro-ophthalmology Ford et al. Figure 2 (B). (coni.) predominantly the medial longitudinal fasciculus, most lesions have diffuse brain stem findings which mask the internuclear ophthalmoplegia.! He reported bilateral internuclear ophthalmoplegia occurring in association with posterior fossa tumors, brain stem infarctions and compressive lesions, neurosyphyllis, and Arnold-Chiari malformations with hydrocephalus. I Since then, bilateral internuclear ophthalmoplegia has been described in a multitude of conditions including brain stem tumors/ head trauma,1 subdural hematoma,4 basilar artery aneurysm,4 branched-chain keto-aminoaciduria,'> and some forms of spinocerebellar degeneration. h Gonyea reported a case of cryptococcal meningitis with unilateral internuclear ophthalmoplegia which later progressed to become bilateraL? Ocular findings similar to bilateral internuclear ophthalmoplegia have been described in myasthenia gravis,! abetalipoproteinemia,8 and nonketotic hyperglycinemia.5 Patients presenting in coma due to overdose of sedative-hypnotics9 or phenytoin!O have been found on caloric testing to have bilateral internuclear ophthalmoplegia which resolves with clearance of the drug. The pathogenetic mechanism of the ophthalmoplegia in our case remains speculative. Gonyea reported a case of unilateral internuclear ophthalmoplegia occurring in association with cryptococcal meningitis in which autopsy showed an endarteritis of the small branches of the basilar artery which supplied the brain stem. A brain stem infarction was present.? Perhaps our patient's inter- June 1983 nuclear ophthalmoplegia was caused by vascular compression, infiltration, or inflammation and thrombosis. It seems more appropriate, however, to postulate that carcinomatous infiltration of the midbrain and medial longitudinal fasciculus was responsible for his presentation as the computerized tomographic head scan showed periaqueductal tumor infiltration. References 1. Cogan, D.G.: Internuclear ophthalmoplegia, typical and dtypiCil1. Arch. Ophthd/mol. 84: 583-589, 1970. 2. Cogdn, D.G., dnd Wray, S.H.: Internuclear ophthalmoplegia as an early sign of brainstem tumors. Neurology 20: 629-633, 1970. 3. Beck, R. W., and Meckler, R.J-: Internuclear ophthdlmoplegia after head traumd. Ann. Ophthalmol. 13: 671-675, 1981. 4. Devereaux, M.W., Brust, J.eM., dnd Keane, J.R.: Internucledf ophthdlmoplegid cdused by subdurdl hematoma. Neurology 27: 251-256,1979. 5. MdcDondld, JT, and Sher, P.K.: Ophthdlmoplegid as a sign of metabolic disease in the newborn. Neurology 27: 971-973, 1977. 6. Weiner, LP., Konigsmark, B.W., Stoll, J.. et al.: Hereditary olivopontocerebellar atrophy with retinal degeneration: Report of a family through six generations. Arch. Neurol. 16: 364-376, 1967. 7. Gonyea, E.F., and Heilman, K.M.: Neuro-ophthalmic aspects of central nervous system cryptococcosis: Internuclear and supranuclear ophthalmoplegia. Arch. Ophtha/mol. 87: 164-168, 1972. 129 INO in Meningitis 8. Yee, RD., Cogan, D.G., and Zee, 0.5.; Ophthalmoplegia and dissociated nystagmus in abetalipoproteinemia. Arch. Ophtha/mol. 94: 571-575, 1976. 9. Simon, R.P.: Forced downward ocular deviation: occurrence during oculovestibular testing in sedative drug-induced coma. Arch. Neurol. 35: 456-458, 1978. 10. Spector, R.H., Davidoff, R.A., and Schwartzman, 130 R.J.; Phenytoin-induced ophthalmoplegia. Neurology 26: 1031-1034,1976. Write for reprints to: Juliz Cruz, MD., Division of Hematology/Oncology, Department of Medicine, North Carolina Baptist Hospital, 300 South Hawthorne Road, Winston-Salem, North Carolina 27103. Journal of Clinical Neuro-ophthalmology |
