About OJO | Search | Ahead of print | Current Issue | Archives | Author Instructions | Reviewer Guidelines | Online submissionLogin 
Oman Journal of Ophthalmology Oman Journal of Ophthalmology
  Editorial Board | Subscribe | Advertise | Contact
https://www.omanophthalmicsociety.org/ Users Online: 1213  Wide layoutNarrow layoutFull screen layout Home Print this page  Email this page Small font size Default font size Increase font size


 
 Table of Contents    
CLINICAL IMAGE
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 117-119  

Viral mononeurities causing partial oculomotor nerve palsy in an 8 month old child


1 Department of Pediatrics, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Ophthalmology, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication29-Jun-2017

Correspondence Address:
Jayitri Mazumdar
176/1 Birji Road, Flat D2, Kadamtala, Garia, Kolkata - 700 084, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-620X.209115

Rights and Permissions
   Abstract 


BACKGROUND: Palsy of the oculomotor nerve is rarely seen in children, and comprehensive guidelines for management and outcome are difficult to find.
CASE: Here we describe a 8 month old boy with left sided ptosis and infero-leteral deviation of left eye and normally reacting pupil and CSF antimeasles antibody titre negative.
OUTCOME: The ptosis improved within 3 weeks with no residual neurodeficit.
MESSAGE: Viral mononeuritis leading to partial 3rd nerve palsy is a rare entity in children till date.

Keywords: Partial CN-III palsy, ptosis, viral mononeurities


How to cite this article:
Mazumdar J, Chakraborti C, Banerjee A, Nandi M. Viral mononeurities causing partial oculomotor nerve palsy in an 8 month old child. Oman J Ophthalmol 2017;10:117-9

How to cite this URL:
Mazumdar J, Chakraborti C, Banerjee A, Nandi M. Viral mononeurities causing partial oculomotor nerve palsy in an 8 month old child. Oman J Ophthalmol [serial online] 2017 [cited 2019 Dec 7];10:117-9. Available from: http://www.ojoonline.org/text.asp?2017/10/2/117/209115




   Introduction Top


Clinical findings of acquired third nerve palsy depend on the affected area of the oculomotor nerve track. It can be divided into partial or complete palsy.

Partial 3rd nerve palsy are more common, and presents with a variable duction limitation of the affected extraocular muscles and with variable degree of ptosis and/or pupil dysfunction.

Among the various etiology of partial oculomotor nerve palsy in children, viral being the most common, having a self limiting course and good prognosis. We here describe an 8 month old child having partial viral mononeurities of oculomotor nerve, presented with left sided ptosis and down and outward deviation of the eyeball with normally reacting pupil, resolved spontaneously, a rare entity.


   Case Top


An 8-month-old boy presented with fever for 9 days and left-sided ptosis from the very 1st day of fever. The fever was moderate grade and intermittent in nature. It was not associated with any rash, joint pain, convulsion, altered sensorium, or any neurodeficit. The child was otherwise playful. On examination, there was left-sided ptosis with eyeball deviated down and out [Figure 1] and [Figure 2]. Pupillary reflex was normal. There was inability to lift the left eyelid. No neurodeficit, with normal tone, power, and reflexes in all the four limbs. Investigations show complete blood count, electrolytes, urea, and creatinine within normal limit.
Figure 1: Left-sided ptosis

Click here to view
Figure 2: Deviation of left eyeball with slightly improved ptosis after 7 days

Click here to view


ANA, ASO titer, pANCA, and cANCA all within normal limit. Magnetic resonance imaging (MRI) of the brain and both orbits along with MRI angio was normal. Cerebrospinal fluid (CSF) study showed lymphocytic pleocytosis with 10 cells/HPF, with normal protein and sugar. IgM and IgG antimeasles antibody in CSF were within normal titer. With supportive management, the child improved. Ptosis and eye deviation resolved almost within 2 weeks [Figure 3] and completely after 3 weeks with no steroids given [Figure 4].
Figure 3: Improvement after 2 weeks follow.up

Click here to view
Figure 4: Complete improvement after 3 weeks

Click here to view


Palsy of the oculomotor nerve is rarely seen in children, and comprehensive guidelines for management and outcome are difficult to find.[1],[2] In a series of 28 children reported by Keith.,[3] CN-III palsy was most often due to trauma, infection, and idiopathic causes, and in a series of 30 children studied by Miller,[4] CN-III palsy was most often congenital or due to traumatic or inflammatory causes. In a study by Schumacher-Feero et al. of the patients with partial CN-III palsy, 47% did not require any alignment surgery because of spontaneous resolution or partial recovery.[5] The association of pediatric oculomotor nerve palsy with inflammatory diseases is well established. It may occur as a part of autoimmune mononeuropathy [6] as a part of ophthalmoplegic migraine,[6] or following antecedent viral infection in the evolution to diffuse ophthalmoplegia in the setting of Miller–Fisher syndrome. Hence, among the causes of ptosis in children, one is infection which may be of viral origin as in our case. Postviral oculomotor nerve palsy is reported in children following measles [7] and norovirus [8] infection. In our case, all autoimmune markers were negative, and CSF measles antibody titer was within normal range. CSF norovirus polymerase chain reaction could not be done due to financial constraints. Transient unilateral third nerve palsy is associated with endoscopic third ventriculostomy and pseudotumor cerebri.[9] Third nerve palsy also has been reported in childhood tubercular meningitis. Here, CSF picture showed only lymphocytic pleocytosis. It has been well established now that oculomotor nerve palsy in children is frequently associated with aneurysm of internal carotid artery and posterior communicating artery.[10] In our case, MRI of the brain along with angiography was normal ruling out all the above possibilities. Thus, having similarity with viral etiology, by the presence of fever and self-limiting course and CSF showing aseptic meningitis, our case becomes a unique one showing unilateral partial third nerve palsy due to viral mononeuritis which is very rare and showed complete recovery without any deficit.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We are thankful to the professor and head, Department of Pediatrics and Ophthalmology, Calcutta National Medical College, for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Helveston EM. Surgical Management of Strabismus: An Atlas of Strabismus Surgery. 4th ed. St. Louis: Mosby; 1993. p. 502-8.  Back to cited text no. 1
    
2.
Pratt-Johnson JA, Tillson G, editors. Paralytic and paretic strabismus. In: Management of Strabismus and Amblyopia: A Practical Guide. New York: Thieme Medical Publishers; 1994. p. 174-7.  Back to cited text no. 2
    
3.
Keith CG. Oculomotor nerve palsy in childhood. Aust N Z J Ophthalmol 1987;15:181-4.  Back to cited text no. 3
[PUBMED]    
4.
Miller NR. Solitary oculomotor nerve palsy in childhood. Am J Ophthalmol 1977;83:106-11.  Back to cited text no. 4
[PUBMED]    
5.
Schumacher-Feero LA, Yoo KW, Solari FM, Biglan AW. Results following treatment of third cranial nerve palsy in children. Trans Am Ophthalmol Soc 1998;96:455-72.  Back to cited text no. 5
[PUBMED]    
6.
Bharucha DX, Campbell TB, Valencia I, Hardison HH, Kothare SV. MRI findings in pediatric ophthalmoplegic migraine: A case report and literature review. Pediatr Neurol 2007;37:59-63.  Back to cited text no. 6
[PUBMED]    
7.
Caksen H, Acar N, Odabas D, Cakin C, Tuncer O, Atas B. Isolated left oculomotor nerve palsy following measles. J Child Neurol 2002;17:784-5.  Back to cited text no. 7
    
8.
Kuki I, Kawawaki H, Okazaki S, Ikeda H, Tomiwa K. Successful steroid pulse therapy for acute unilateral oculomotor nerve palsy associated with norovirus infection. No To Hattatsu 2008;40:324-7.  Back to cited text no. 8
[PUBMED]    
9.
Chansoria M, Agrawal A, Ganghoriya P, Raghu Raman B. Pseudotumor cerebri with transient oculomotor palsy. Indian J Pediatr 2005;72:1047-8.  Back to cited text no. 9
[PUBMED]    
10.
Ko JH, Kim YJ. Oculomotor nerve palsy caused by posterior communicating artery aneurysm: Evaluation of symptoms after endovascular treatment. Interv Neuroradiol 2011;17:415-9.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
   
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case
    References
    Article Figures

 Article Access Statistics
    Viewed1362    
    Printed15    
    Emailed0    
    PDF Downloaded67    
    Comments [Add]    

Recommend this journal