A rare cause of headache-the importance of a tissue diagnosis and perseverance

A 64 year old diabetic hypertensive milkman presented in September 2011 with 4 months progressive constant right frontotemporal retro–orbital pain. It was worse at night affecting sleep with slight right field blurring and later vomiting. Full examination including blood pressure was normal with acuities 6/9. Tension type headache was considered. Initial brain CT was reported as normal. With concern about giant cell arteritis steroids were trialled although ESR was 8 and CRP 25 with no other clinical features: pain reduction was short–lived and temporal artery biopsy negative. Symptoms worsened despite analgesics. Noting his sister's Wegener's and his weekly positive ANCA the differential began to expand. Claustrophobia delayed MRI several months until admission became necessary for pain control when he had new right partial ptosis. Examination showed asymptomatic upgaze diplopia and MRI a right orbital apex soft tissue mass, likely present on the CT when reviewed, along with minor proptosis and distension of the optic nerve. Whilst additional diagnoses then included meningioma and lymphoma, regional MDT proposed metastatic carcinoma advising against biopsy due to lesion location. Hence investigation for malignancy but LDH, CT Chest/Abdomen/Pelvis and PET CT were normal/negative. Two weeks into admission he developed complete right visual loss due to compressive neuropathy. Differentials of aspergillosis and mucormycosis were raised and biopsy and debridement prop...
Source: Journal of Neurology, Neurosurgery and Psychiatry - Category: Neurosurgery Authors: Tags: Immunology (including allergy), Cranial nerves, Headache (including migraine), Neurooncology, Pain (neurology), Stroke, Hypertension, CNS cancer, Ophthalmology, Pain (palliative care), Anxiety disorders (including OCD and PTSD), Radiology, Disability, Dru Source Type: research