An 80-Year-Old Woman With Left-Sided Headache and Diplopia

Abstract

An 80-year-old white woman with a history of hyperthyroidism treated with radioactive iodine ablation, gastroesophageal reflux disease complicated by Barrett esophagus, osteoarthritis, breast cancer status post-bilateral mastectomy, and diverticulosis presented with severe left-sided headache and diplopia. Three weeks prior to presentation, she developed a sharp pain located over the left temporal, parietal, and occipital regions. It was associated with exquisite scalp tenderness. Over the next few days, the pain progressed, involving the left side of the face, including the periorbital region. There was no radiation of the pain, and she had little relief with over-the-counter acetaminophen. She also experienced earache, sore throat, and left jaw pain with mastication. The patient saw a dentist for these symptoms, and she was diagnosed with temporomandibular joint disorder. She was prescribed a mouth guard; however, despite its use, her symptoms progressed to a point where she was unable to open her mouth at times, and her jaw felt swollen. Diplopia started 4 days prior to presentation. She experienced this intermittently for 24 hours before it became constant. She saw an ophthalmologist who diagnosed her with a right eye abduction deficit presumed to be a cranial nerve 6 (CN6) palsy. The patient then went to the emergency department for further evaluation. Review of systems was notable for fatigue, recent 10-pound weight loss, and intermittent myalgias, but there were no fevers, chills, dizziness, dysphagia, dysarthria, weakness, or numbness. Family history included coronary artery disease, diabetes, and various cancers. She was a 40-pack-year smoker, but quit 12 years ago. Her general physical examination was only notable for a blood pressure of 164/77 mm Hg. Neurological examination was notable for the inability to fully abduct the right eye. Fundoscopic examination was negative for papilledema. Strength was 5/5 throughout with normal tone. Serum laboratory analysis showed mild leukocytosis (12 200/mm3), normocytic anemia (hematocrit of 32.9% and mean corpuscular volume of 80.6 fL compared to hematocrit 40.2% 2 months prior), and thrombocytosis (675 000/mm3). Erythrocyte sedimentation rate (ESR) was 76 mm/h (reference range 0-30) and C-reactive protein (CRP) was 73.65 mg/L (reference range 0.30-8.00). A lumbar puncture (LP) was performed with a normal opening pressure of 15 cm H2O. The white blood cell count was 1 in tube 1 and 2 in tube 4. The red blood cell count was 9 in tube 1 and 1 in tube 4. The glucose was slightly elevated at 79 mg/dL (reference range 40-70), and the protein was normal at 41 mg/dL. The viral and bacterial studies of the cerebrospinal fluid (CSF) were unremarkable. Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast was unremarkable except for moderate supratentorial white matter changes. Magnetic resonance angiogram of the head and neck with and without contrast was normal.