Hospital Practice
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Painful Ophthalmoplegia In a Patient with SLE Elizabeth McDonald, Catherine Marino & Daniel Cimponeriu To cite this article: Elizabeth McDonald, Catherine Marino & Daniel Cimponeriu (1992) Painful Ophthalmoplegia In a Patient with SLE, Hospital Practice, 27:11, 41-44, DOI: 10.1080/21548331.1992.11705521 To link to this article: http://dx.doi.org/10.1080/21548331.1992.11705521
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [University of Toronto Libraries]
Date: 18 June 2016, At: 19:43
The Problem Patient
Painful Ophthaltnoplegia In a Patient with SLE ELIZABETH McDONALD, CATHERINE MARINO,
and DANIEL CIMPONERIU St. John's Queens Hospital. Elmhurst. N.Y.. and Mary Immaculate Hospital, Jamatca, N.Y.
Hospital Practice 1992.27:41-44.
Case Presentation A 42-year-old woman known to have systemic lupus erythematosus for 20 years was admitted with diplopia, eye swelling, and a steady pain in and above the left eye. Her headache and eye pain had persisted for several days. The visual acuity was OD 20/20, OL 20/30. On physical examination, there was chemosis of the left eye and swelling of the eyelid. A 3-mm proptosis of the left eye compared with the right was found (exophthalmometry, OD 20/0L 23). Pupils were equally reactive to light and accommodation. There was no nystagmus. Complete paralysis ofleft lateral gaze was noted, but there was no impairment of adduction. Ocular motility on the right was unaffected. Findings on funduscopic examination of the cranial and peripheral nerves were normal. There was no ptosis, and facial and corneal sensation was intact. The patient had a history of
Dr. McDonald is Director, Department of Medicine, and Chief, Division of Rheumatology, and Dr. Cimponeriu is an Attending Physician, Department of Medicine, St. John's Queens Hospital, Elmhurst, N.Y. Dr. Marino is Chairman, Department of Medicine, and Staff Rheumatologist, Mary Immaculate Hospital, Jamaica, N.Y.
lupus membranoproliferative glomerulonephritis, recurrent arthralgia and arthritis, thrombocytopenia, venous thrombophlebitis, cerebral infarction, amenorrhea, hypothyroidism, and difficulty with mental tasks and recall. In addition, she was positive for antinuclear antibodies and lupus anticoagulant and was hypocomplementemic. She had been on corticosteroid therapy for many years and, more recently, on hydroxychloroquine. The patient was also taking warfarin for recurrent phlebitis and tapering doses of prednisone in the weeks prior to admission. Her current daily regimen included 10mgofprednisone, 200 mg ofhydroxychloroquine, alternating 5-mg and 2.5-mg doses of warfarin, and 0.025 mg oflevothyroxine. In addition to circulating lupus anticoagulant, the patient was known to have anticardiolipin antibodies (lgG and IgM) but a negative VORL. Laboratory evaluation on admission revealed a normal hemogram and SMA-18. Prothrombin time was 14.1 (normal, 11. 7) and partial thromboplastin time was 54.3 (normal, 24.2). Trace proteinuria, depressed C3 and C4 levels, and a mildly elevated sedimentation rate were unchanged from previous visits. CT and MRI scanning of the
brain revealed old right cerebellar and occipital infarcts but no evidence of a mass lesion behind the eye. Imagingofthe pons, sinuses, and the area around the sixth nerve was normal. Prednisone was increased to 30 mg twice daily, and over the next three days improvement in eye movement was noted. By day 10, the lateral rectus palsy had totally resolved, and prednisone was decreased to 40 mg daily.
The Case in Context Diplopia is a symptom that frequently provokes neurologic or ophthalmic consultation. True binocular diplopia is most frequently associated with paresis or paralysis of the abducent (sixth) nerve. However, involvement of extraocular muscles, as in patients with thyroid orbitopathy, orbital myositis, myasthenia gravis, or muscle entrapment secondary to traumatic fracture, may also produce diplopia. Other etiologies include brain stem lesions, cavernous sinus, and vascular lesions in patients with diabetes or hypertension. Ophthalmoplegia has been reported to occur in patients with SLE, presumably on a vascular basis. Unilateral internuclear ophthalmoplegia has occurred in the setting of cerebral infarcts and cerebral vasculitis. Painful ophthalmoplegia with exophthalmos that responded to corticosteroid therapy has been reported in SLE patients and may be consistent with the TolosaHunt syndrome. The syndrome involves chronic granulomatous inflammation of the superior orbital fissure or cavernous sinus. The clinical picture includes periorbital or hemicrania! pain and ipsilateral ocular motor nerve palsies af(conttnues) Hospital Practice November I5, I992
41
BIAXIN" (C~rithromycin) Filmtab•Tablets BRIEFSUMMAJIY CONSULT PACKAGE INSERT FOfl FUU PRESCRIBING INFORMATlOH
DIPLOPIA
(continued)
INDICATIOHSANDUSAGE BIAXIN !Cianthromycm) IS 1nd1tated lor the trtatment ol m1ld to mOOerate lnf&ehons cause-j by suscept1ble stra1ns ol lhe dts1gnated m1croorgan,sm1 m tne condlllons I1Sitd below
UpptrResplralorylractlnlec:tlooi P!iaryr'91NT01'61II1Sdu&1oSirepttxrewspyogentS Acule rt\aXI~ary s1nll&ills due to lowefResp~rator;Tractlllfectk.na
Slr&pkJCOCClls pnt(lfflOI'IIIB
Acute bactenal uacerb1110n of chron1c bronchrtll dua to Humopl!iiUI rnfluenzae. ftloraxellaCI!arrlliiii)(Slrepttiaxct.os~
Pneumon1a due to Mycoplasma pneumomu or Streplococcus pneumonrae S~1n and S1.1n Structure lntecl!oos d~~t to S!l,ollytococcvs IUflus or Streptococcus
U!ICOmpbcated
p)':)gliiWAbseeiaesU$Uity~SIJrgtealtW\age
COHTR.UIOICATlOHS
.......
Clar~thromycm IS contraindiCated 1n palients w1th 1 k~own hypersens11iVIIy to ctar1lhromycm f!Yihromycn'll)r811yolthemacrohdlantibKlllcs
CLJJUTHROMYCIN SHOOLD NOT BE USED IN PREGNANT WOllEN EXCEPT IN CL.IIICAL CIRCUIISTANCES 'MER£ NO .lLTEIINATM Tt1EilAPY IS APPROPRIATE. IF PfiECW.NCY OCCURS WHILE TAKING THIS DRUG, THE PATIENT SHOULD BE ApPRISED OF THE POTENTIAL HAZARD TO TliE FETUS. CLARITHROMYCIN HAS DEIIIONSTAAT£0 ADVERSE EFFECTS ON PR£GNANCY OUTCOME ANOOR EMBRYQ.fETAL DEVELOPMENT IN MONKEYS, RATS, liCE, AND RA88ITS AT DOSES THAT PRODUCED PUSMA LEVELS 2 TO 17 TIMES THE S£AUM LEVELS ACHIEVED IN HUMANS TREATED AT TliE MAXIMUM RECOMMENDED ltUIIIAN DOSES.(SEEPREGNANCY.) hludomlmbrlnoul colltllllu been rtpOftld with lllllly 1M llltlblcllrllllglllb, Including ft'IICtOIIOII,Ifldllll'frqtlnll'o'lrilytrommlldtolllltniWIIng. Thenlorl.ftlllmpoftlntto COI'IIialrlfllld119101111nPifllntlwhOprllllllwlthdilntiiiiUbllqulnllolhtiCimiftlllrllloal
--
Treatmenlwrth~enalagentSOerJ PerrttrlaM elal Thet.:Ofll)aratl'le elfrcacy and satety o1 ctafllhrom)'CII1 and amoK)'CIIton rn !he trearmenl ol outpatients "M1h aCUle ma~rllal)' smus~IS JAnflrrncrobChemortrer 1991,27(suppl A) 83-90 Cedor'rsaregrsteredtrademarl:.oiEl Lrl~andCompany and Cettn'rsa regrstereotrademari:.~AIIen
&Hanburys
44
Abb:lttlaboratones
NorlhCI'rrca9:JIL60064USA PnntedmUSA
2048641R
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
Painful Ophthalmoplegia In a Patient with SLE Elizabeth McDonald, Catherine Marino & Daniel Cimponeriu To cite this article: Elizabeth McDonald, Catherine Marino & Daniel Cimponeriu (1992) Painful Ophthalmoplegia In a Patient with SLE, Hospital Practice, 27:11, 41-44, DOI: 10.1080/21548331.1992.11705521 To link to this article: http://dx.doi.org/10.1080/21548331.1992.11705521
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [University of Toronto Libraries]
Date: 18 June 2016, At: 19:43
The Problem Patient
Painful Ophthaltnoplegia In a Patient with SLE ELIZABETH McDONALD, CATHERINE MARINO,
and DANIEL CIMPONERIU St. John's Queens Hospital. Elmhurst. N.Y.. and Mary Immaculate Hospital, Jamatca, N.Y.
Hospital Practice 1992.27:41-44.
Case Presentation A 42-year-old woman known to have systemic lupus erythematosus for 20 years was admitted with diplopia, eye swelling, and a steady pain in and above the left eye. Her headache and eye pain had persisted for several days. The visual acuity was OD 20/20, OL 20/30. On physical examination, there was chemosis of the left eye and swelling of the eyelid. A 3-mm proptosis of the left eye compared with the right was found (exophthalmometry, OD 20/0L 23). Pupils were equally reactive to light and accommodation. There was no nystagmus. Complete paralysis ofleft lateral gaze was noted, but there was no impairment of adduction. Ocular motility on the right was unaffected. Findings on funduscopic examination of the cranial and peripheral nerves were normal. There was no ptosis, and facial and corneal sensation was intact. The patient had a history of
Dr. McDonald is Director, Department of Medicine, and Chief, Division of Rheumatology, and Dr. Cimponeriu is an Attending Physician, Department of Medicine, St. John's Queens Hospital, Elmhurst, N.Y. Dr. Marino is Chairman, Department of Medicine, and Staff Rheumatologist, Mary Immaculate Hospital, Jamaica, N.Y.
lupus membranoproliferative glomerulonephritis, recurrent arthralgia and arthritis, thrombocytopenia, venous thrombophlebitis, cerebral infarction, amenorrhea, hypothyroidism, and difficulty with mental tasks and recall. In addition, she was positive for antinuclear antibodies and lupus anticoagulant and was hypocomplementemic. She had been on corticosteroid therapy for many years and, more recently, on hydroxychloroquine. The patient was also taking warfarin for recurrent phlebitis and tapering doses of prednisone in the weeks prior to admission. Her current daily regimen included 10mgofprednisone, 200 mg ofhydroxychloroquine, alternating 5-mg and 2.5-mg doses of warfarin, and 0.025 mg oflevothyroxine. In addition to circulating lupus anticoagulant, the patient was known to have anticardiolipin antibodies (lgG and IgM) but a negative VORL. Laboratory evaluation on admission revealed a normal hemogram and SMA-18. Prothrombin time was 14.1 (normal, 11. 7) and partial thromboplastin time was 54.3 (normal, 24.2). Trace proteinuria, depressed C3 and C4 levels, and a mildly elevated sedimentation rate were unchanged from previous visits. CT and MRI scanning of the
brain revealed old right cerebellar and occipital infarcts but no evidence of a mass lesion behind the eye. Imagingofthe pons, sinuses, and the area around the sixth nerve was normal. Prednisone was increased to 30 mg twice daily, and over the next three days improvement in eye movement was noted. By day 10, the lateral rectus palsy had totally resolved, and prednisone was decreased to 40 mg daily.
The Case in Context Diplopia is a symptom that frequently provokes neurologic or ophthalmic consultation. True binocular diplopia is most frequently associated with paresis or paralysis of the abducent (sixth) nerve. However, involvement of extraocular muscles, as in patients with thyroid orbitopathy, orbital myositis, myasthenia gravis, or muscle entrapment secondary to traumatic fracture, may also produce diplopia. Other etiologies include brain stem lesions, cavernous sinus, and vascular lesions in patients with diabetes or hypertension. Ophthalmoplegia has been reported to occur in patients with SLE, presumably on a vascular basis. Unilateral internuclear ophthalmoplegia has occurred in the setting of cerebral infarcts and cerebral vasculitis. Painful ophthalmoplegia with exophthalmos that responded to corticosteroid therapy has been reported in SLE patients and may be consistent with the TolosaHunt syndrome. The syndrome involves chronic granulomatous inflammation of the superior orbital fissure or cavernous sinus. The clinical picture includes periorbital or hemicrania! pain and ipsilateral ocular motor nerve palsies af(conttnues) Hospital Practice November I5, I992
41
BIAXIN" (C~rithromycin) Filmtab•Tablets BRIEFSUMMAJIY CONSULT PACKAGE INSERT FOfl FUU PRESCRIBING INFORMATlOH
DIPLOPIA
(continued)
INDICATIOHSANDUSAGE BIAXIN !Cianthromycm) IS 1nd1tated lor the trtatment ol m1ld to mOOerate lnf&ehons cause-j by suscept1ble stra1ns ol lhe dts1gnated m1croorgan,sm1 m tne condlllons I1Sitd below
UpptrResplralorylractlnlec:tlooi P!iaryr'91NT01'61II1Sdu&1oSirepttxrewspyogentS Acule rt\aXI~ary s1nll&ills due to lowefResp~rator;Tractlllfectk.na
Slr&pkJCOCClls pnt(lfflOI'IIIB
Acute bactenal uacerb1110n of chron1c bronchrtll dua to Humopl!iiUI rnfluenzae. ftloraxellaCI!arrlliiii)(Slrepttiaxct.os~
Pneumon1a due to Mycoplasma pneumomu or Streplococcus pneumonrae S~1n and S1.1n Structure lntecl!oos d~~t to S!l,ollytococcvs IUflus or Streptococcus
U!ICOmpbcated
p)':)gliiWAbseeiaesU$Uity~SIJrgtealtW\age
COHTR.UIOICATlOHS
.......
Clar~thromycm IS contraindiCated 1n palients w1th 1 k~own hypersens11iVIIy to ctar1lhromycm f!Yihromycn'll)r811yolthemacrohdlantibKlllcs
CLJJUTHROMYCIN SHOOLD NOT BE USED IN PREGNANT WOllEN EXCEPT IN CL.IIICAL CIRCUIISTANCES 'MER£ NO .lLTEIINATM Tt1EilAPY IS APPROPRIATE. IF PfiECW.NCY OCCURS WHILE TAKING THIS DRUG, THE PATIENT SHOULD BE ApPRISED OF THE POTENTIAL HAZARD TO TliE FETUS. CLARITHROMYCIN HAS DEIIIONSTAAT£0 ADVERSE EFFECTS ON PR£GNANCY OUTCOME ANOOR EMBRYQ.fETAL DEVELOPMENT IN MONKEYS, RATS, liCE, AND RA88ITS AT DOSES THAT PRODUCED PUSMA LEVELS 2 TO 17 TIMES THE S£AUM LEVELS ACHIEVED IN HUMANS TREATED AT TliE MAXIMUM RECOMMENDED ltUIIIAN DOSES.(SEEPREGNANCY.) hludomlmbrlnoul colltllllu been rtpOftld with lllllly 1M llltlblcllrllllglllb, Including ft'IICtOIIOII,Ifldllll'frqtlnll'o'lrilytrommlldtolllltniWIIng. Thenlorl.ftlllmpoftlntto COI'IIialrlfllld119101111nPifllntlwhOprllllllwlthdilntiiiiUbllqulnllolhtiCimiftlllrllloal
--
Treatmenlwrth~enalagentSOerJ PerrttrlaM elal Thet.:Ofll)aratl'le elfrcacy and satety o1 ctafllhrom)'CII1 and amoK)'CIIton rn !he trearmenl ol outpatients "M1h aCUle ma~rllal)' smus~IS JAnflrrncrobChemortrer 1991,27(suppl A) 83-90 Cedor'rsaregrsteredtrademarl:.oiEl Lrl~andCompany and Cettn'rsa regrstereotrademari:.~AIIen
&Hanburys
44
Abb:lttlaboratones
NorlhCI'rrca9:JIL60064USA PnntedmUSA
2048641R
