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Images in Neurology |

Oculomotor Nerve Palsy as the Presenting Symptom of Gummatous Neurosyphilis and Human Immunodeficiency Virus Infection Clinical Response to Treatment

Christopher W. Hess, MD1,2,3; Steven S. Rosenfeld, MD4; Stanley R. Resor Jr, MD1
[+] Author Affiliations
1Department of Neurology, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, New York, New York
2University of Florida Center for Movement Disorders and Neurorestoration, Gainesville
3Malcom Randall VA Medical Center, Gainesville, Florida
4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
JAMA Neurol. 2013;70(12):1582-1583. doi:10.1001/jamaneurol.2013.1485.
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A 39-year-old man presented with 5 months of worsening right eyelid ptosis, fatigue, and diplopia, which progressed to include anorexia, low-grade fevers, and arthralgias. An examination revealed a subtle macular rash on his trunk, arms, and palms. The right pupil was dilated to 5 mm without direct or consensual response to light or accommodation with inferotemporal deviation of the eye. Extraocular movements were impaired in all directions except abduction, with near-complete ptosis of the eyelid. Serum studies showed a positive rapid plasma reagin test result (to 1:64) and reactive fluorescent treponemal antibodies and Lyme antibodies. Cerebrospinal fluid analysis demonstrated a total protein level of 0.084 g/dL (to convert to grams per liter, multiply by 10.0); a glucose level of 47 mg/dL (to convert to millimoles per liter, multiply by 0.055); a white blood cell count of 18/μL (to convert to ×109 per liter, multiply by 0.001); red blood cell count of 3 × 106/μL (to convert to ×1012 per liter, multiply by 1.0); 91% lymphocytes; 9% monocytes; a polymerase chain reaction test result negative for Lyme disease; and a Venereal Disease Research Laboratory test result reactive to 1:2. Subsequent human immunodeficiency virus (HIV) antibody and Western Blot tests were positive with a CD4 lymphocyte count of 307 and a viral load of 30 000.

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Figure 1.
Magnetic Resonance Imaging of the Brain at Presentation

Axial views show right third cranial nerve lesion (A [arrowheads]), and coronal views show temporal lobe lesion (B [arrowheads]). FLAIR indicates fluid-attenuated inversion recovery.

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Figure 2.
Magnetic Resonance Imaging of the Brain at Follow-up

Axial views showing residual enhancement of the third cranial nerve (A [arrowhead]), and coronal views show resolution of the temporal lobe lesion (B). FLAIR indicates fluid-attenuated inversion recovery.

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