Recurrent, alternating Tolosa-Hunt syndrome.

Area of Science:

• Neurology
• Ophthalmology

Background:

• Tolosa-Hunt syndrome (THS) is a rare idiopathic granulomatous inflammation of the cavernous sinus or superior orbital fissure.
• It typically presents with painful ophthalmoplegia, often involving the third, fourth, and sixth cranial nerves, and sensory loss in the first and/or second divisions of the trigeminal nerve.

Observation:

• A 24-year-old woman initially presented with right-sided facial pain, blurry vision, right pupil-sparing third nerve palsy, and decreased trigeminal sensation.
• Initial investigations, including infectious, rheumatologic, and neoplastic workups, were negative, leading to a diagnosis of THS.
• Corticosteroid treatment resolved her symptoms; however, 10 months later, she developed contralateral (left-sided) symptoms including facial pain, double vision, and left third nerve palsy.

Findings:

• Magnetic Resonance Imaging (MRI) revealed enhancement in the right cavernous sinus during the initial presentation.
• A subsequent MRI demonstrated an enhancing left cavernous sinus following the contralateral recurrence.
• This contralateral presentation and associated MRI findings have not been previously reported in the literature.

Implications:

• This case underscores the possibility of rare contralateral recurrence in Tolosa-Hunt syndrome.
• The unique MRI findings in this recurrent contralateral case add to the radiological spectrum of THS.
• Further research may elucidate the underlying mechanisms of THS recurrence and its varied presentations.