細菌感染による偽性Tolosa-Hunt症候群の症例および文献的考察

A Case of Pseudo Tolosa-Hunt Syndrome with Bacterial Infection and Literature Review

要旨　細菌感染によると思われる，Tolosa-Hunt症候群類似の症状と経過を呈した症例を報告した。症例は32歳男性。右側の眼窩部痛，複視を主訴に近医を受診。右の動眼神経麻痺と三叉神経1枝領域の感覚低下を示し，MRIでは右海綿静脈洞の肥厚と造影剤の増強効果を認めたことから，Tolosa-Hunt症候群が疑われた。ステロイドの内服加療により，疼痛と脳神経障害は一時的に緩解したが，ステロイド減量中に再燃し，その後も症状は寛解増悪を繰り返したため，当科に入院した。入院中の症状増悪時の髄液検査で，入院当初認めなかった好中球優位の細胞数増多と蛋白の上昇を認めた。抗生剤投与で症状，検査所見とも改善した。髄液の培養検査では起炎菌は同定できなかったが，画像上の特徴やペニシリン系の抗生物質が効果を示した治療経過から細菌感染により同症候群を呈した可能性が最も疑われた。

We report a case with recurrent orbital pain and unilateral cranial nerve paresis mimicking Tolosa-Hunt syndrome. However, these features were most likely caused by bacterial infection because of beneficial response to antibiotics therapy. A 32-year-old man developed severe right orbital pain and diplopia. Neurological examination revealed right oculomotor paresis and 1st division of the right trigeminal nerve dysfunction. MR imaging revealed thickness of right cavernous sinus region with marked gadolinium enhancement. Cerebrospinal fluid （CSF） examination was initially normal. Treatment with steroid showed marked improvement. However soon after tapering of steroid dosage, his symptoms recurred and deteriorated. He was referred to our hospital because of second opinion. Neurological examination still showed right oculomotor paresis and 1st division of the right trigeminal nerve dysfunction with orbital and retro-orbital pain. Re-examination of CSF showed pleocytosis with neutrocytes dominancy and elevated protein concentration. Intravenous treatment with penicillin was initiated with marked improvement. There have been reported cases with bacterial infection resulting pseudo Tolosa-Hunt syndrome, which have good response to antibiotics treatment with excellent prognosis. It is speculated that bacterial infection might cause clinical features mimicking Tolosa-Hunt syndrome in our case.

（Received : October 6, 2004）