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The case
A 67-year-old man presented with acute onset severe generalised headache and diplopia. He had membranous glomerulonephritis, had failed immunosuppressant therapy, and had started haemodialysis 3 months before presentation. He was on three antihypertensive agents and had missed a few doses in the week before his admission. He had no other illness and no recent change of medication.
On examination, his blood pressure was 201/95 mm Hg. He reported diplopia on all eye movements, although with no clinically obvious ophthalmoplegia. Visual acuity was 6/6 bilaterally and fundoscopy was normal. The rest of the neurological examination was normal. CT scan of head was normal.
His blood pressure control was difficult, requiring intravenous labetalol, and his symptoms persisted despite blood pressure lowering.
On day 3, he developed dysconjugate eye movements with incomplete right eye abduction. A MR scan of brain was reported as showing a small haemorrhage in the right basal ganglia (figure 1).
MRI T2 slice from day 3 of admission.
Question 1
What is the most likely cause of his progressive symptoms?
Comment
The treating physicians assumed his headache and diplopia were due to the MRI findings, but on review of the images, it is clear that the ‘haemorrhage’ was unlikely to be acute, …
Footnotes
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Contributors RSG cared for the patient once the diagnosis had been made and co-wrote the case study. NMM made the diagnosis and co-wrote the case study.
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Competing interests None.
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Patient consent Obtained.
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Ethics approval Northland District Health Board.
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Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by Simon Rinaldi, Oxford, UK and Hugh Willison, Glasgow, UK.
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