Lower cranial nerve palsy, aseptic meningitis and hydrocephalus: unusual presentation of primary antiphospholipid syndrome

Abstract

Presentation of primary antiphospholipid syndrome (APS) is usually untrustworthy and unusual presentations are difficult to diagnose on the basis of clinical features alone. This is true especially in young and elderly patients. Cerebral venous thrombosis (CVT) is less frequent than arterial thrombosis in APS. CVT has a wide spectrum of signs and symptoms, which may evolve suddenly or over weeks. It mimics many neurological conditions such as meningitis, encephalopathy, benign intracranial hypertension and stroke. Headache is the most frequent symptom in patients with CVT, and is present in about 80% of cases. The most common pattern of presentation is with a benign intracranial hypertension-like syndrome. Sixth cranial nerve palsy usually manifests as a false localising sign. Patients may have recurrent seizures. Cranial nerve syndromes are seen with venous sinus thrombosis. We present a case of APS with lower cranial nerve palsy, aseptic meningitis and hydrocephalus initially treated as tuberculous meningitis.

Figure 1

Midthoracic oesophageal diverticulum on barium swallow.

Figure 2

Computed tomography (CT) scan showing hydrocephalus.

Figure 3

Magnetic resonance venogram showing absent flow in the left transverse sinus.

Figure 4

Computed tomography scan of the abdomen showing thrombus as a filling defect in the inferior vena cava.