Abnormal Eye Movement in a 5-year-old Girl.

Abstract

1. Jessica X. Ouyang, MD* 2. Edward E. Kim, MD† 3. John J. Manaloor, MD†,‡ 1. *Brown University, Providence, RI 2. †Riley Hospital for Children, Indianapolis, IN 3. ‡Ryan White Center for Pediatric Infectious Diseases and Global Health, Indianapolis, IN A 5-year-old previously healthy girl was taken to an outpatient ophthalmologist by her guardian due to abnormal eye movements for a few weeks. On examination she is found to have papilledema and is sent to the emergency department for magnetic resonance imaging (MRI) of the brain and orbits. She is subsequently admitted to the pediatric hospitalist service after obtaining head imaging. Her history reveals that she had a febrile illness approximately 1 month earlier and was diagnosed as having a right otitis media at a local emergency department (ED). Amoxicillin was started, but during the following week she began to have eye movement changes, headache, clumsiness, and a stiff neck. She returned to the ED after completing 7 days of amoxicillin and was instructed to stop the amoxicillin and start cefdinir. The patient was unable to tolerate cefdinir owing to adverse effects after a trial of 3 days, and she returned for the third time to the ED. She received and completed a 10-day course of amoxicillin-clavulanic acid. Although the fevers, headache, and neck pain had all resolved, her eye symptoms persisted, prompting her to be seen by an outpatient ophthalmologist, who referred her for an MRI. On admission, the physical examination revealed an afebrile, developmentally normal, and well-appearing 5-year-old, whose vital signs were within normal limits for age but whose examination revealed incomplete abduction of her eyes bilaterally, with the left worse than the right. Her examination was also significant for an erythematous, nonbulging right tympanic membrane with good light reflex. The remainder of her examination, including gait, and range of motion of her neck, were unremarkable. Her history and ancillary study results taken together reveal the diagnosis. ### Differential Diagnosis Papilledema alone, but especially in conjunction with abducens nerve palsy, is highly indicative of increased intracranial pressure (ICP). Elevated ICP in …