A 75-year-old woman presented with horizontal binocular diplopia, right-sided ptosis, and a new headache that was progressive over 3 days. She reported difficulty opening her jaw, pain when chewing, and a 2.3-kg weight loss. The week prior, she experienced left-sided ptosis that persisted for 2 days and subsequently resolved. She denied vision changes, eye pain, scalp tenderness, and myalgias. Past medical history included schizophrenia, hypothyroidism, and supraventricular tachycardia.
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Her examination demonstrated normal visual acuity in both eyes. Pupils were equal, round, and reactive. There was right upper-eyelid ptosis. Extraocular motility demonstrated limitation of elevation and abduction bilaterally (Figure 1). Results of dilated fundus examination were normal, and the remainder of her neurologic examination results were normal. Her eye movements and ptosis did not change with fatiguability, rest, or an ice-pack test. Investigations revealed a C-reactive protein level of 292 mg/L (normal, <10 mg/L; to convert to milligrams per deciliter, divide by 10) and erythrocyte sedimentation rate of 93 mm/h (normal, <30 mm/h). A lumbar puncture demonstrated normal opening pressure, cell count, and glucose and protein levels. Magnetic resonance imaging with contrast of the brain demonstrated diffuse edema and enhancement of the scalp, skull base, neck, and paraspinal soft tissues, as well as T2 hyperintensity and enhancement of the extraocular muscles bilaterally. An additional test was obtained, and a diagnosis was made.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Jeannette Y. Stallworth, MD, Department of Ophthalmology, University of California, San Francisco, 490 Illinois St, 5th Floor, Room 5X8, San Francisco, CA 94143 (firstname.lastname@example.org).
Published Online: July 25, 2022. doi:10.1001/jamaneurol.2022.1982
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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