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Diplopia and Ptosis as the Initial Presentation of a Prostate Carcinoma: A Case Report
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.329567
Sir, Multiple cranial neuropathies (MCN) are characterized by damage of two or more cranial nerves (CNs). One of the first hypotheses to be considered is a lesion in the cavernous sinus.[1] Tumors are the most common cause of MCN, with prostate carcinoma as the most frequently involved neoplasm.[2] We report a case of an elderly man presenting with diplopia and ptosis. Further investigation revealed a metastatic prostate carcinoma. To date, it is one of the first reports in the literature of a prostate neoplasm being diagnosed by MCN. The disease's prognosis is not optimistic.[2] A 78-year-old male with a history of hypertension, smoking, and alcoholism presented with gradual-installing left-sided ptosis and vertical diplopia in the previous month. He denied any visual disturbances. He also complained of an intense chronic thoracic and lumbar pain and a weight loss of 30 kg in the 6 months preceding the visit. The initial neurological exam revealed palsy of left CN III and paresis of CNs IV, V (V1), and VI, with little preservation of lateral gaze and paresthesia and pain over the ophthalmic nerve territory. No other physical alterations were noted. On hospitalization, a head computed tomography (CT) scan showed diffuse cortical atrophy, cavernous sinuses asymmetry, clivus thickening, osteitis, and atherosclerosis of the intracavernous portion of the left internal carotid artery. A head magnetic resonance imaging scan showed a 5.7 × 4.2 × 2.2 cm mass, with isointensity on T1-weighted images and hyperintensity on T2-weighted images, in the left portion of the clivus [Figure 1]. A chest CT scan revealed bilateral subpleural nodules and solid parenchymal nodules in the lungs, besides sclerotic lesions in the thoracic vertebral column, sternum, and costal arches. In addition, an abdominal CT scan demonstrated sclerotic lesions in the lumbar vertebral column and iliac bones. Chest and abdomen CT scans are not shown. Cerebrospinal fluid (CSF) contained 1 leukocyte/μL, 16 erythrocytes/μL, 81 mg glucose/dL, and 19 mg total protein/dL.
Tumor marker serum prostate-specific antigen was greater than 100 μg/L. Pathologic examination of the transrectal ultrasound-guided prostate biopsy disclosed a Gleason score: 4 + 5 = 9 acinar adenocarcinoma of the prostate. He was referred to the oncology service and underwent palliative therapy with dexamethasone and morphine for painful episodes to reduce symptoms and improve his quality of life. Less than 60 days after the first admission to the emergency room, he returned to the service because of intense pain in his right knee, edema, and hyperemia following a fall from standing height with worsening of his general state. In delirium and hyperactive, he was treated with opioids. Again, undergoing hospitalization, his wife opted for treating him with opioids instead of adopting invasive methods. He died 1 day later, less than 2 months after the initial presentation. Approximately 4% of cancer patients have skull-base metastases from distant tumors.[3] The cavernous sinus is the most common site. In a review about this type of metastasis, sellar and parasellar regions were involved in 29% of 279 cases. Although clinically silent, those metastases may present as pain and MCN. Prostate carcinoma is the most common metastatic neoplasm to reach the base of the skull in men, totalizing 38.5% of cases.[4] Further, in an analysis of 1589 autopsies, prostate cancer generated hematogenic metastases in 35% of the events, 90% of which were in direction to the osseous tissue, with 8% reaching the skull.[5] In an analysis of 979 cases of MCN, tumors were the major cause (30%). Metastases represented 16% of the neoplasms, following schwannomas (17%). Cavernous sinus was the most affected region (25%). CNs III, IV, and VI were the most involved—in 13%, 6%, 14%, and 22% of the cases, respectively. In combination, the most affected nerves were III and VI, in 281 cases (28.7%) and V with VI, in 214 (21.8%). The mean of affected CNs was 2.7 per patient in the analysis.[6] Although the abducens nerve is generally the most affected in MCN,[6],[7],[8],[9],[10] the most limited CN in the described case was the oculomotor. There are similar reports to the current one in the literature. A cavernous syndrome was diagnosed after a lesion in the cavernous sinus by an already diagnosed prostate carcinoma, with metastasis in the base of the skull. CNs III, IV, and VI were injured, with periorbital pain, headaches, mild ptosis, and ophthalmoplegia as the main symptoms. Metastasis to the L2 vertebral body was present, resembling the present case.[8] The first of another two reports was about a nonkeratinizing squamous cell carcinoma in the clivus, compromising CN VI. The second case was an MCN affecting CNs III, IV, V (V1), and VI by an underlying large B-cell malignant lymphoma.[9] In terms of treatment for the described conditions, McDermott, et al. (2004) suggest palliative radiotherapy because of the improvement of MCN symptoms.[10] In O'Sullivan, et al. (2004) retrospective study, 44% of patients diagnosed with MCN caused by metastases in the base of skull lived for less than 2 months after therapy completion, as this type of manifestation occurs in more advanced stages of the pathology and/or when it is refractory to hormone therapy.[2] Under the presented conditions, palliative care offers a comfortable alternative to the patient by attenuating their symptoms and providing them an improved quality of life. We emphasize the possibility of a prostate carcinoma to be detected by CNs complaints, such as diplopia and ptosis, when the disease already is in advanced stage. Considering the patient's unfavorable prognosis, palliative care offers comfort by reducing the condition's debilitating symptoms. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1]
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