Journal of Neuro-Ophthalmology:
March 2004 - Volume 24 - Issue 1 - pp 96-97
Letters To The Editor
Recurrent Para-Infectious Third Nerve Palsy with Cisternal Nerve Enhancement on MRI
Nazir, Sayeda A. BS; Murphy, Scott A. MD; Siatkowski, R. Michael MD
Author Information
Department of Ophthalmology Dean A. McGee Eye Institute University of Oklahoma College of Medicine, Oklahoma City, Oklahoma rmichael-siatkowski@ouhsc.edu
Editor's note: The Journal of Neuro-Opthalmology welcomes letters as written or e-mail correspondence. Send e-mail to: jdtrobe@umich.edu.
To the Editor:
We have examined a child with recurrent unilateral third cranial nerve palsy in whom magnetic resonance imaging (MRI) demonstrated acute enhancement of the cisternal portion of the affected nerve.
The first episode occurred in April, 2001, when the patient was 11 months old. Two weeks after hospitalization for viral pneumonitis, he developed complete right-sided ptosis and paresis of the extraocular muscles innervated by the third cranial nerve. The right pupil was 5 mm and sluggish; the left pupil was 3 mm and briskly reactive. The remainder of his neuro-ophthalmologic examination and cerebrospinal fluid analysis was normal.
MRI showed enhancement of the oculomotor nerve at its exit from the brainstem (Fig. 1a). After 3 days of intravenous methylprednisolone, the ptosis dramatically improved; after 2 months, the ophthalmoplegia and pupillary abnormalities had resolved. Repeat MRI was normal (Fig. 1b).
The patient received no further medical treatment apart from that for amblyopia. In July 2003, at the age of 39 months, he developed a recurrent pupil-involving right third cranial nerve palsy following an acute viral gastroenteritis. Examination showed complete ptosis and paresis of the muscles innervated by the right third cranial nerve. The right pupil was 7 mm and sluggish, and the left pupil was 4 mm and briskly reactive to light. The remainder of the neuro-ophthalmologic examination was normal.
Repeat MRI showed enhancement of the right third cranial nerve in a region identical to that implicated in the first episode (Fig. 2). After 2 weeks of therapy with oral prednisolone, 5 mg three times daily, the ptosis and ophthalmoplegia slightly improved. Two months later, there was minimal ptosis and the ophthalmoplegia had completely resolved.
Although postviral cranial neuropathies most commonly affect the sixth cranial nerve, involvement of the third cranial nerve has been reported (1-6). MRI shows enhancement of the cisternal portion of the nerve. Similar enhancement occurs in ophthalmoplegic migraine (7-9), neuroma (10), and meningitis (5). To our knowledge, this is the first report of recurrent para-infectious third cranial nerve palsy.
Acknowledgment
Supported in part by an unrestricted grant from Research to Prevent Blindenss, New York, New York.
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