Palpebral ptosis, fixed mydriasis and exophthalmos: an uncommon presentation of new diabetes mellitus

Abstract

A 60-year-old woman was admitted to our Department of Metabolic Diseases of the University of Padova for new onset of diabetes, exacerbation of bronchial asthma and likely pulmonary infection. The patient reported fatigue, shortness of breath, cough, hemoptysis, polyuria, weight loss, and fever 2 weeks before onset. The clinical history was characterized by bronchial asthma (III degree of asthma severity, according to the international staging GINA) and bronchiectasis, treated with steroids, beta 2 agonists, montelukast, and theophylline. The patient had a bronchoscopy 4 days prior to admission, which revealed abundant purulent secretions (the cultures were negative for infection). Nevertheless, she was treated with antibiotics Levofloxacin 500 mg/daily and Ceftazidime 2 g/daily. The physical examination showed tachycardia, dry skin and mucosa, rhonchi and wheezing heard on lung auscultation, right palpebral ptosis with exophthalmos, fixed mydriasis and ocular abduction deficit (that, according to the patient, had been present for about 2 weeks), and a slight deficit in the lower right visual field. Laboratory tests revealed hyperglycemia (554 mg/dL), HbA1c 11.5 %, neutrophilic leukocytosis (15,140/dL), increased inflammatory markers (CRP 208 mg/L), hyponatremia (127 mmol/L), alteration of thyroid function markers (TSH 0.58 mL/UI, fT3 1.61 pmol/L, fT4 15.25 pmol/L, TSI \0.9 UI/L). There were normal levels of renal and liver function, absence of ketones and normal acid–base balance (pH 7.42, pCO2 22.2 mmHg, pO2 81.4 mmHg). The chest X-ray study showed a small right lung consolidation. The electrocardiogram showed sinus tachycardia without other remarkable signs. We started intravenous rehydration and insulin infusion, parenteral antibiotic therapy with Meropenem 3 g/daily and enhanced steroid therapy (Methylprednisolone 60 mg/daily). Considering the neurological signs, based on a hypothesis of a cavernous sinus thrombosis, a head CT scan was performed, showing the presence of a hypodensity in the right frontal-basal parenchyma. Therefore, a head MRI with angiography of the intracranial vessels was obtained, which showed an apparent ischemic lesion in the territory of the anterior cerebral artery and opacification of the right maxillary sinus and mucosal thickening (Fig. 1), so the initial hypothesis was excluded. Moreover, a CT scan was performed to study the facial sinuses and orbits, which revealed an opacification of the frontal sinus bilaterally, complete opacification of the right maxillary sinus, ethmoid cells and sphenoid sinuses partially opacified, thickening of the periorbital fat in the posterior portions, and hyperdensity of the lesion in the right frontal brain. Given the extensive pansinusitis, we added Macrolides to the antibiotic therapy at the recommendation of our ENT colleagues. The patient showed a progressive reduction of inflammatory markers, although there was a further loss of vision. Therefore, in agreement with the neuroradiologist, the patient underwent a contrast enhanced MRI, which showed an extension of the frontal-basal lesion with a purulent component, compatible with intracerebral abscess and retro-orbital cellulitis. The consulting neurosurgeons decided not to operate. On the other hand, after an ENT and ophthalmologic colleagues re-evaluation, given the rapid deterioration of clinical and radiological objectivity, the S. Galasso (&) N. C. Chilelli S. Burlina N. Vitturi A. Avogaro Department of Medicine, University of Padova, Padova, Italy e-mail: galasso.sil@gmail.com