Typical Sounding Atypical Diagnostic Conundrum -- A Rare Case of Mycobacterium Avium Complex (MAC) Presenting with Multiple Cranial Nerve Involvement

Background MAC infections rarely cause symptomatic systemic infection in immunocompetent healthy individuals. This case brings to light a rare such presentation that gives us a learning point about keeping a strong pre-clinical suspicion for this condition in patients whom lung imaging reveals suspicious cavitary lesions. Starting empiric therapy while awaiting culture results may be considered after weighing risks and benefits in order to achieve the morbidity and mortality associated with the disease. Case report A 54 year-old white male presented for evaluation of progressively worsening vertigo, imbalance, vertical diplopia, facial diplegia, bilateral hyperacusis followed by hearing loss, dysphagia, and dysarthria together with unintentional 40 pound weight loss, headache, neck stiffness, and productive cough over 5 months. His neurological exam showed multiple cranial nerve abnormalities. Contrast enhanced MRI head showed mild thickening and enhancement of cranial nerves V, VII, and VIII bilaterally. Biopsy of a cavitary left upper lobe lung lesion noted on CT chest and PET scan along with specimen culture surprisingly revealed Mycobacterium avium complex (MAC). Despite starting treatment, he died 6 weeks after discharge from presumed disseminated MAC. This rare case of MAC in an immunocompetent individual presenting with only multiple cranial neuropathies has not been previously reported. Conclusion MAC related CNS infections are very unusual in immunocompetent patient. Our case highlights one such unique presentation of an immunocompetent male who presented with multiple cranial nerve palsy that was ultimately diagnosed to be secondary to MAC infection. Given its rarity, it is very likely to lead to a delay in diagnosis and this could further delay treatment and poor outcome as in our patient. More extensive reporting of this rare CNS MAC infection in immunocompetent individuals could help understand the disease presentation better and might aid in earlier diagnosis and initiation of treatment

Visual Field Deficits in Patients with Headache Disorders: A 2- year Prospective Cohort Study

Primary and secondary headache disorder patients are often seen in ophthalmology clinics with visual symptoms. Their exam is usually normal but visual field abnormalities may be seen

MRI Restricted Diffusion in Lymphomatous Optic Neuropathy

Diffusion-weighted imaging (DWI) has been largely applied to the diagnosis of acute cerebral infarction, but restricted diffusion has been reported in brain parenchymal lymphoma1 and attributed to the dense cellularity of this tumor

Vertical Diplopia from Skew Deviation in a Patient with Thalamic Infarct

Skew deviation has been reported in thalamic infarcts but is not as common as vertical gaze paresis. We describe a patient with chronic thalamic and pontine infarcts who presented with a transient new onset vertical diplopia due to skew deviation

Egg in Your Face (Presentation Video)

Confusion; Headache; VomitingAn 8-year old female with a 2-day history of confusion, headache and vomiting.VA: 20/70 OD, 20/50 OS; RAPD OSMRINeoplastic oligodendroglial cells in the leptomeninges.IV steroids; Antineoplastic agents1. Mathews MS, Pare LS, Kuo JV, Kim RC. Primary leptomeningeal oligodendrogliomatosis. J Neurooncol. 2009 Sep;94 (2):275-8. 2. Rossi S, Rodriguez FJ, Mota RA, Dei Tos AP, Di Paola F, Bendini M, Agostini S, Longatti P, Jenkins RB, Giannini C.Primary leptomeningeal oligodendroglioma with documented progression to anaplasia and t(1;19)(q10;p10) in a child. Acta Neuropathol. 2009 Oct;118 (4):575-7. 3. Ozkul A, Meteoglu I, Tataroglu C, Akyol A Primary diffuse leptomeningeal oligodendrogliomatosis causing sudden death. J Neurooncol. 2007 Jan;81(1):75-9. 4. Chen R, Macdonald DR, Ramsay DA. Primary diffuse leptomeningeal oligodendroglioma. Case report. J Neurosurg. 1995 Oct;83(4):724-8

Computed Tomography (CT) Demonstration Of Dorsal Midbrain Hemorrhage In Traumatic Fourth Cranial Nerve Palsy

The location of injury to the fourth cranial nerve in closed head trauma is uncertain. In most cases, brain imaging fails to show a lesion