Painful Ophthalmoplegia Mimicking Tolosa-Hunt Syndrome in A 46 Years Old Patient: A Diagnostic Challenge

Abstract

Background: Painful ophthalmoplegia is an uncommon neuro-ophthalmic syndrome with a wide differential diagnosis, including inflammatory, infectious, vascular, and neoplastic disorders. Tolosa-Hunt syndrome (THS) is a rare cause of painful ophthalmoplegia; however, because it is a diagnosis of exclusion, intracranial space-occupying lesions (SOL) and other structural abnormali­ties must be carefully ruled out before establishing the diagnosis. This case report aims to remind clinicians of rare conditions that may still be encountered in everyday clinical practice.

Case Presentation: A 46-year-old man presented with a 10-day history of left painful ophthalmo­plegia accompanied by blurred vision, diplopia, eyelid swelling, excessive tearing, and left upper extremity weakness. Ophthalmologic examination demonstrated severe visual impairment, marked limitation of extraocular movements, conjunctival hyperemia, and eyelid edema. Neuro­logical examination revealed left upper extremity monoparesis and left peripheral facial nerve palsy. Labo­ratory investigations showed mild leukocytosis. Non-contrast head computed tomography demonstrated soft tissue swelling at retrobulbar sinistra  and left maxilaris sinusitis but was insufficient to exclude an underlying intracranial structural lesion. Based on the clinical presenta­tion, suspected THS was considered; however, the presence of additional neurological deficits raised concern for an intracranial SOL. Intravenous methylprednisolone (125 mg every 12 hours) resulted in rapid improvement of orbital pain, eyelid edema, and conjunctival hyperemia, although severe visual impairment persisted.

Conclusion: This case illustrates the diagnostic dilemma of painful ophthalmoplegia, in which suspected Tolosa-Hunt Syndrom and intracranial Space Occupying Lesions share overlapping clinical manifestations. Although an early response to corticosteroid therapy favored an inflammatory process, persistent neurological deficits and visual impairment underscored the necessity of contrast-enhanced magnetic resonance imaging and further diagnostic evaluation before confirming THS. Early recognition of structural mimics is essential to avoid delayed diagnosis and inappropriate treatment.