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Case report of pediatric tuberculoma with occulomotor and trochlear nerve palsy

Bharti Nigam, Sumaiya Shamsi, Ritika Mullick, Pragati Garg

Introduction: Peculiar case of a tuberculoma in the midbrain, leading to superior oblique and inferior rectus palsy along with a moderate degree of ptosis of the right eye. Presenting features: 5 year-old female patient with complaints of fever, drooping of the right upper eyelid and uprolling of the right eye. 15 degree Hypertropia of the right eye with head tilt on the left side. The pupils showed sluggish reaction. Total restriction of ocular movements in the downward gaze suggesting the under action of the superior oblique and inferior rectus muscle. Moderate degree of unilateral ptosis. Vertical diplopia in downward gaze. Investigations: Cranial MRI with Intravenous contrast revealed a well-defined enhancing lesion measuring about 10 × 8 mm with small non-enhancing area noted within with significant edema in the midbrain. Presence of a tuberculoma in midbrain involving the trochlear nerve nucleus, the dorsolateral and central nucleus of the occulomotor nerve. Discussion: Partial fascicular oculomotor palsy leading to isolated inferior rectus palsy caused by midbrain infarction suggesting the possible selective involvement of an individual fascicle. Compression of the central caudal nucleus of the occulomotor nerve by the edema present around the tuberculoma gives rise to moderate ptosis in the patient. Patient received anti tubercular treatment. The improvement of the ocular symptoms after one month of anti-tubercular treatment confirmed the finding of a tuberculoma.