Korean Journal of Ophthalmology 2008;22:201-204 ISSN : 1011-8942 DOI : 10.3341/kjo.2008.22.3.201 A Case of Oculomotor Nerve Palsy and Choroidal Tuberculous Granuloma Associated with Tuberculous Meningoencephalitis Sunghyuk Moon, MD, Junhyuk Son, MD, Woohyok Chang, MD Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea We report a rare case of oculomotor nerve palsy and choroidal tuberculous granuloma associated with tuberculous meningoencephalitis. A 15-year-old male visited our hospital for an acute drop of the left eyelid and diplopia. He has been on anti-tuberculous drugs (isoniazid, rifampin) for 1 year for his tuberculous encephalitis. A neurological examination revealed a conscious clear patient with isolated left oculomotor nerve palsy, which manifested as ptosis, and a fundus examination revealed choroidal tuberculoma. Other anti-tuberculous drugs (pyrazinamide, ethambutol) and a steroid (dexamethasone) were added. After 3 months on this medication, ptosis of the left upper eyelid improved and the choroidal tuberculoma decreasedin size, but a right homonymous visual field defect remained. When a patient with tuberculous meningitis presents with abrupt onset oculomotor nerve palsy, rapid re-diagnosis should be undertaken and proper treatment initiated, because the prognosis is critically dependent on the timing of adequate treatment. Korean J Ophthalmol 2008;22:201-204 ⓒ 2008 by the Korean Ophthalmological Society. Key Words: Choroidal tuberculous granuloma, Oculomotor nerve palsy, Ptosis, Tuberculous meningoen- cephalitis Tuberculous meningitis is a chronic disease, and cranial nerve palsies are common manifestations. Neuro-ophthalmic involvement, a part of its presentation spectrum, is important, and numerous reported neuro-ophthalmologic complications are combinations of oculomotor palsies, pupil abnormalities, disc changes suggestive of papillitis, papilledema, or optic atrophy and choroidal tubercles.1 It is always necessary to take tuberculous meningitis into consideration when an abrupt deterioration of a neuro-ophthalmic nature is noted, becauseearly diagnosis and treatment are important. In particular, when a neuro-ophthalmic complication occurs despite anti-tuberculosis therapy, it may be that the tuberculosis is resistant to treatment and that additional anti-tuberculosis therapy is required. The present case report provides an example of rare multiple ophthalmic involvement associated with tuberculous meningitis during anti-tuberculosis therapy. Received: January 28, 2008 Accepted: August 6, 2008 Reprint requests to Junhyuk Son MD. Department of Ophthal- mology, Yeungnam University College of Medicine, 317-1 Daemyung -dong, Nam-gu, Daegu 705-717, Korea. Tel: 82-53-620-3444, Fax: 82-53-626-5936, E-mail: sjh@med.yu.ac.kr * This study was presented as a poster at the 97th Annual Meeting of the Korean Ophthalmological Society in April 2007. Case Repo rt A 15-year-old male visited our hospital for an acute drop of the left eyelid and diplopia of 4 days duration, which developed overnight. One year ago, he was diagnosed as having tuberculous pleurisy (Fig. 1), tuberculous encephalitis (Fig. 2a), and a 2/3 optic disc-sized choroidal tuberculoma (Fig. 3a). At that initial presentation, he had a stuporous mental status. Polymerase chain reaction for mycobacterium tuberculosis on chest pleural biopsy tissue was positive. He was admitted and medicated with anti-tuberculous drugs (isoniazid, rifampin, streptomycin, pyrazinamide, ethambutol) and steroid for 2 months. After anti-tuberculous medication, his mental status became alert and his fever and headache symptoms improved. He was discharged on medication (isoniazid, rifampin) and was followed up in a pediatric clinic without discomfort. However, subsequently, acute drop of left eyelid occurred and brain MRI showed an increase in the size and number of a multifocal granuloma at the brain base, and increased brain swelling at midbrain and left thalamus (Fig. 2b). He was then re-admitted and a neurological examination revealed a clear conscious patient with isolated left oculomotor nerve palsy, which manifested as ptosis of the left upper eyelid (Marginal reflex distance (MRD) : +4 (OD), -1 (OS), Levator muscle function (LF) : 11 mm (OD), 6 mm (OS)) (Table 1) and paralysis of superior rectus and inferior oblique muscles on the left, but with no apparent papillary defect (Fig. 4a). 201