Pachymeningitis with pseudo-Foster Kennedy syndrome

Pearls & Oy-sters: Trigeminal Cystic Schwannoma Presenting With Foster Kennedy Syndrome, Sixth Nerve Palsy, and Focal Seizures

Foster Kennedy syndrome refers to a finding of optic atrophy in one eye from direct compression of the optic nerve by a mass lesion and contralateral papilledema in the nonatrophic optic nerve caused by an increased intracranial pressure. When the fundoscopy finding is not due to a direct compressive mass, the term pseudo-Foster Kennedy syndrome is used; this can be caused by any process or processes that result in optic atrophy in one eye and optic disc edema in the other. Identifying Foster Kennedy syndrome in a patient calls for expedient neuroimaging looking for an intracranial mass lesion. In this article, we present the case of a patient presenting with vision loss and Foster Kennedy syndrome who was found to have a large trigeminal cystic schwannoma. While several other accompanying symptoms were not evident from the patient complaint, a careful history and physical examination revealed additional localizing clues: unilateral sensory changes in the face and pterygoid and masseter atrophy, unilateral cranial nerve VI palsy, and episodes of intense déjà vu sensation, which were presumed to represent temporal lobe-onset focal aware seizures. Trigeminal schwannomas are a rare entity, and they are even more rarely cystic. This case highlights an unusual scenario where a slow expansion of the tumor ultimately resulted in vision loss and presentation of the patient to medical attention.

Sequential NAION presenting as pseudo Foster Kennedy syndrome

PURPOSE

To review recurrent NAION as a cause for PFK syndrome.

METHODS

In an observational study patients presenting with sudden loss of vision were evaluated. We reviewed patients presenting with disc edema on one side and optic atrophy in contralateral eye on fundus examination. Their visual field defects and fundus fluorescein angiography was assessed.

RESULTS

Of the 7 patients evaluated 4 (57.1%) were females. Mean age at presentation was 53.7±11.9years. Mean duration between the two episodes was 12.7months (range: 2-30). The visual acuity of presenting eye ranged from 6/9 to worse counting fingers close to face.

CONCLUSIONS

The diagnosis in a PFK presentation is essentially one of exclusion. Patients with NAION are at risk for recurrence in fellow eye, thereby presenting as PFK syndrome. NAION should be considered as a differential especially when imaging and other laboratory investigations are not suggestive of any compressive lesion.

Hypertrophic cranial pachymeningitis in MPO-ANCA-related vasculitis: a case report and literature review

A 75-year-old woman presented with rapidly progressive glomerulonephritis with positive results for anti-myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA). Corticosteroid therapy was successfully introduced. However, 7 months later, magnetic resonance imaging revealed marked swelling in the falx cerebri and high density regions were apparent on gallium scintigraphy, leading to diagnosis of hypertrophic cranial pachymeningitis (HCP). Symptoms improved with intensified corticosteroid therapy, but radiological examination 9 months later revealed right nasal sinus inflammation accompanied by osteolytic change. Granulomatosis with polyangiitis (Wegener's) was finally diagnosed. HCP is an important complication in MPO-ANCA-related vasculitis, and needs to be considered during the clinical course.

Idiopathic Hypertrophic Cranial Pachymeningitis Associated With Intermediate Uveitis

The authors report a case with idiopathic hypertrophic cranial pachymeningitis associated with intermediate uveitis. The patient complained of decreased vision in both eyes, especially the right. Ophthalmic examination revealed right optic disc pallor, bilateral vitritis, and cystoid macular edema. Magnetic resonance imaging revealed marked enhancement of a dural lesion. The macular edema responded well to medical treatment. Intermediate uveitis has not yet been reported in the context of idiopathic hypertrophic cranial pachymeningitis.

Foster Kennedy Syndrome in a Case with Retinitis Pigmentosa

A 57-year-old woman suffering from long-term visual disturbance due to retinitis pigmentosa noted an even more severe deterioration of her left vision for several months. On ophthalmologic examination, her vision was 1/60 in the right eye and light perception (LP) in the left eye. An RAPD sign was noted in her left eye. Bilateral fundus revealed the typical appearance of severe retinitis pigmentosa. The optic disc of her right eye was markedly swollen, whereas that of the left eye was pale. Under the impression of the Foster Kennedy syndrome, a magnetic resonance imaging (MRI) study was arranged revealing a well-encapsulated round mass with a contrast enhancement of about 4.45 cm in diameter located in the left frontal lobe. The patient might have ignored the visual disturbance in her left eye caused by tumor compression because of her illness of retinitis pigmentosa, which had caused her visual disturbance since childhood.

P-ANCA cranial pachymeningitis: a case report

Pachymeningitis is an inflammatory process that thickens the dura mater. This disease has various etiologies including infectious, neoplastic, or autoimmune diseases. We present the case of a patient who developed cranial pachymeningitis with a clinical and biological picture suggestive of a neurological form of vasculitis. A 51-year-old woman developed rhinitis, otitis media, headaches, and deterioration of her condition after a course of recombinant hepatitis B vaccine. After a booster dose of the vaccine, she developed unilateral visual loss and impairment of multiple cranial nerves. Blood analysis showed inflammation and presence of antimyeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA). Cranial magnetic resonance imaging (MRI) showed pachymeningitis. A complete remission was obtained with immunosuppressive therapy. The initial clinical presentation and subsequent remission under immunosuppressive therapy were suggestive of a vasculitis with nervous system involvement. Though vasculitis was not proven histologically in this patient, we believe that MPO-ANCA-related autoimmunity provoked the patient's disease as already reported in similar cases. As pachymeningitis is a fibrosing process, early recognition and treatment of an autoimmune etiology, even in the absence of previous pulmonary or renal involvement, is required to prevent definitive neurological impairment.