A rare presentation of bilateral abducens nerve palsy with papilledema in tuberculous meningitis

• Deekshanya J,*  
• Kale Satya Geethika,  
• Hannah Ranjee Prasanth,  
• Ramesh Kannan S

Abstract

We present a classical case of a 30-year-old female who presented with bilateral abducens nerve palsy and papilledema. Her initial presentation was a holocranial headache for the past 20 days and restricted eye movements in both eyes for the past 10 days. Her best-corrected visual acuity was 6/9 in both eyes. The Hirschberg test showed 15 degrees esotropia in the left eye. Dilated fundus examination revealed a hyperemic disc with blurred margins and dilated, tortuous vessels in both eyes. Visual evoked potentials suggest demyelinating axonal optic neuropathy involving both optic nerves. MRI was otherwise normal and showed no cerebral haemorrhage or cerebral venous thrombosis. A lumbar puncture was done. The cerebrospinal fluid opening pressure was less than 5cm of water. Cerebrospinal fluid analysis showed colourless, clear fluid with RBC-5/ul, WBC-247/ul, polymorph was 8%, lymphocytes were 92% with degenerated cells in the background. She was diagnosed with tuberculous meningitis. Abducens nerve palsy is a common manifestation of intracranial conditions, especially in meningitis or idiopathic intracranial hypertension. Optic neuropathy in tuberculosis is mostly a result of chronic papilledema due to meningitis. Tuberculous meningitis is known to cause papilledema and bilateral abducens nerve palsy, which can be worrying for the patient. Tuberculosis must be considered in such patients, as prevention is better than cure. Although there are many national programmes to identify and treat tuberculosis early, young people are afflicted by such debilitating forms of extrapulmonary tuberculosis. This public health challenge must be tackled as a national priority.

Keywords

Abducens nerve palsy, lateral nerve palsy, papilledema, tuberculous meningitis,optic neuropathy