D Kumudhan, A Jamieson, R Sanders Department of ophthalmology, Queen Margaret Hospital, Dunfermline , Scotland
Correspondence to: Mr Dharmalingam Kumudhan, Ward 25 , Ninewells Hospital & Medical School, Dundee
Email: kumudhan@hotmail.com
SMJ 2005 50(1): 31-32
Abstract:
Adult onset, multiple oculo-motor nerve palsies are usually due to neoplasia and trauma.1, 2 We report two cases whose initial presenting sign was oculo-motor cranial nerve palsy and were later found to have metastatic carcinoma.
Case one
A 40 year old health worker presented with intermittent diplopia of three weeks duration. She was found to have left sixth cranial nerve palsy. Physical and neurological examination and investigations (Full Blood Count, plasma viscosity, and clotting screen) were normal. She was a heavy smoker. Past medical history revealed that she had haemoptysis two years earlier and had a chest x-ray and bronchoscopy, both reported as normal. An MRI scan at presentation showed an isolated discrete lesion reported as pontine haemorrhage. Two weeks later, she developed lagophthalmos. Examination showed that she had developed vertical nystagmus and a left lower motor neuron seventh nerve palsy. A second MRI scan showed enlargement of the previously noted pontine lesion, crossing the midline with surrounding high signal suggestive of primary tumour such as glioma (Fig 1). A thoracic CT scan showed a right posterior upper lobe, irregular 28 mm opacity consistent with squamous carcinoma of the lung. She developed secondary deposits in her groin (confirmed by fine needle aspiration). She received palliative chemotherapy and died four months after initial presentation.
Case two
A 63 year old technology manager presented with sudden onset headache, general malaise and vertical diplopia due to a left superior oblique palsy. Neurological examination and investigations (pulse, blood pressure, FBC, glucose, plasma viscosity and chest x-ray) were normal. A week later he had left sided peri-ocular pain and drooping of the upper eyelid. He had developed left sided partial 3rd and 6th cranial nerve palsies and sensory symptoms suggestive of fifth nerve involvement. An MRI scan showed bulky thickening of the medial wall of the cavernous sinus, representing an infiltrative lesion (Fig 2). Despite normal liver function tests, ultrasound of the abdomen showed multiple large liver metastases and also a 17 mm hypo-echoic area within the renal cortex representing a possible primary tumour. Liver biopsy was not possible as his general condition deteriorated and the markers of liver dysfunction increased. He died three weeks later and post-mortem was refused. Comment Diplopia secondary to brain metastasis, with a known primary has been reported extensively in the literature3-9. Keane et al and Ishikawa et al have reported 3rd nerve palsy on patients known to have lung carcinoma.3, 6 Juneau et al reported three cases of metastatic secondaries to the pituitary presenting with extra-ocular movement weakness.3,10 In the two cases we have reported diplopia was the presenting symptom of advanced metastatic carcinoma, where the primary was still unknown. Review of the literature indicates that this is an unusual initial presenting symptom.9 These cases highlight the importance of thorough history and examination and early imaging in progressive multiple oculo-motor nerve palsies.
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