Villatoro et al. Journal of Medical Case Reports 2011, 5:315 http://www.jmedicalcasereports.com/content/5/1/315 of the tongue toward the right, right-side hypotonia and muscle twitching (Figures 1 and 2). Results of the rest of the physical examination were normal. Blood analysis results revealed an alkaline phosphatase level of 350 UI/L (normal range 44 to 147 UI/L) but no other significant alterations. In view of the paresis of the four lower cranial nerves, a CT scan of the larynx and neck was performed; the CT scan revealed an asymmetri- cal union between the clivus and the right occipital con- dyle, adjacent to the jugular foramen, with increased ground-glass bone density. There was no visible lesion to the bone cortex or soft tissues. This study was comple- mented with an MRI scan, which revealed a bone lesion producing a hypointense signal at sequences T1 and T2. Administration of a gadolinium contrast agent produced a moderate degree of enhancement at the base of the skull, affecting the right occipital condyle and part of the right side of the basilar bone (Figure 3). The image corre- sponded to a moderately space-occupying blastic lesion, visible in the CT scan, which slightly decreased the cali- ber of the jugular foramen and the condylar canal. There- fore, fibrous dysplasia, Paget’s disease and metastasis were considered in the differential diagnosis. Subsequently, an additional radiographic examination of the lumbar column and pelvis was carried out; this exami- nation did not reveal any lesions suggestive of Paget’s dis- ease. A bone gammagraphy was then requested, and images showed multiple pathological foci of tracer uptake in the right maxilla, the rib cage, right scapula, spine and pelvis. These foci were compatible with disseminated bone metastases. The blood analysis was repeated, and tumor markers were studied. The initial prostate-specific antigen (PSA) value was 21.30 ng/mL. A physical examination revealed an enlarged prostate with a hard consistency, destructured in the left lobe. Because there was a strong suspicion of prostate Page 2 of 3 Figure 2 Paresis of cranial nerve XII. neoplasm, a biopsy was performed. The anatomic pathology findings were bilateral common adenocarci- noma, with a Gleason grade of 8 (4+4), affecting 60% of the tissue. There was no presence in the periprostatic adipose tissue and no perineural infiltration. Following the diagnosis of stage IV prostate adenocar- cinoma by metastatic bone dissemination with Collet- Sicard or jugular foramen syndrome, hormone treatment was begun with an antiandrogen. Then, 15 days later, a luteinizing hormone-releasing hormone (LHRH) analog Figure 1 Paresis of cranial nerve XI. Figure 3 MRI scan with moderate degree of enhancement at the base of the skull, affecting the right occipital condyle and part of the right side of the basilar bone.