Tolosa Hunt Syndrome(THS)

Introduction

Tolosa Hunt Syndrome(THS) is a painful opthalmoplegia caused by idiopathic granulomatous inflammation of cavernous sinus or superior orbital fissure. It is a diagnosis of exclusion with an estimated annual incidence of one case per million per year(1U). We present a patient who presented with isolated 6th nerve palsy and was diagnosed for THS.



Case Report

A 50 year old Hispanic female with no relevant medical history presented with isolated pain in the left eye since 2 weeks and diplopia of sudden onset. She denied fever, trauma, recent surgery or travel. On examination, patient had lateral gaze paralysis , decreased visual acuity due to poor gaze fixation and diplopia. She did not have any other cranial nerve deficits. The rest of the systemic examination including the nervous system was unremarkable. MRI brain did not show any focal lesions. Lumbar puncture, Antibody assays for Connective Tissue Disorders, Lyme’s Disease ,Serum Protein Electrophoresis and other laboratory examinations failed to reveal any abnormality. After consultation with neurology and ophthalmology and their thorough investigation, patient was diagnosed for THS. She was started on prednisone 1mg/kg dose daily with resolution of symptoms in a few days.



Discussion

THS is described as “episodic orbital pain associated with paralysis of one or more of the third, fourth, and/or sixth cranial nerves”(6U). It is seen at almost any age without any gender or race discrimination. MRI shows changes in 44% of case only. In most cases it is diagnosed when all other vascular, neoplastic and inflammatory causes of painful opthalmoplegia are ruled out. Orbital pseudotumor is an important differential diagnosis as it differs only in relation to anatomic localization. Remission is possible in 40% of cases with ipsilateral, bilateral or contralateral involvement. Steroids are the mainstay for treatment. Initially given high dose upto 80mg daily, gradually the doses are tapered off. If need be other immunosuppresants like methotrexate, cyclosporine, mycophenolate mofentil and azathioprine can be tried. Usually the radiological improvement lags behind the clinical response to therapy. Though essentially a benign disease, neurological deficits are possible requiring long term immunosuppresion. The purpose of this case report is to reinforce the fact that THS can be a severely debilitating disease with dangerous consequences but at the same time if diagnosed appropriately, it can completely cure the patient. Thus THS should be at the back of the mind of all internists when a patient presents with similar signs and symptoms.




History

Patients present with usually severe retro-orbital or periorbital pain of acute onset. This pain may be described as constant and "boring" in nature.
Diplopia related to ophthalmoparesis follows the onset of pain (in rare cases, the ophthalmoparesis precedes the pain, sometimes by several days).
Patients may report visual loss. This is noted if the inflammation extends into the orbit to affect the optic nerve, and it is not a factor in disease limited to the cavernous sinus.
Paresthesias along the forehead may be described if the first division of the trigeminal nerve is involved.
THS is most often unilateral, although bilateral cases have been described.
THS frequently mimics other conditions; a single characteristic that is pathognomonic for this process does not exist. As such, realizing that this is a diagnosis of exclusion becomes even more important. Many of the processes that are found within the differential diagnosis of THS can have significant associated morbidity if not diagnosed and treated appropriately.

Physical

Painful ophthalmoparesis or ophthalmoplegia is the hallmark of this syndrome.
In addition to the optic and trigeminal nerves (V1, rarely V2 distribution), any of the ocular motor nerves may be involved. The oculomotor and abducens nerves are most commonly affected. Evidence of incomplete third nerve palsy with or without pupillary sparing may be present. Conversely, inflammatory involvement of the sympathetic nerves passing through the interior of the cavernous sinus may produce Horner syndrome with miosis. The combination of unilateral oculomotor palsy and Horner syndrome increases the localization specificity for the cavernous sinus.
Ptosis may be observed related to oculomotor palsy. Lid swelling is more likely to occur with orbital disease rather than inflammation limited to the cavernous sinus.
Mild proptosis and/or optic disc edema may be noted if the orbit is involved.
Evidence of trigeminal nerve involvement is suggested by loss of the ipsilateral corneal reflex.

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The International Headache Society criteria for THS include the following:

Episode(s) of unilateral orbital pain for an average of 8 weeks if left untreated
Associated paresis of the third, forth, or sixth cranial nerves, which may coincide with onset of pain or follow it by a period of up to 2 weeks
Pain that is relieved within 48 hours of steroid therapy initiation Exclusion of other conditions by neuroimaging and (not compulsory) angiography

Causes
The cause of THS is unknown (idiopathic).

Relaxation - key to better health

Relaxation has long been known as one of the best ways to improve your health. Many experts cite stress as the number one killer in the world today.
August 15th is national relaxation day. So here are some tips to help you along the way.


Cheers

HTBW Editor

History
To relax is to become less tense, rigid, or firm. Sounds simple enough, but how difficult it seems to truly achieve a relaxed state, considering the fast pace of daily life and the many extensive obligations that people build up throughout the course of their lives. What is casually refereed to as stress are the physical and mental symptoms caused by persistent conflicts and specific problems, which are easily caused when one's energy is stifled from being over-worked, over-tired, and otherwise over-extended. Unwinding from time to time is vital to maintaining your health as stress diminishes productivity, motivation, and concentration, can result in chronic physical manifestations and be a negative factor in more serious illness. Instead of sapping your own energy by staying stressed out, take National Relaxation Day to heart and relax!

Tradition
Let go of your daily hang-ups by setting up a relaxing outlet for the negative energy they can create. That may mean taking some time alone with a journal, engaging yourself in a creative or physical activity such as painting or yoga, or learning some meditation techniques. All you really need to confront your anxieties and release stress is a bit of privacy, and a resolved mind, body, and spirit. Identifying the precise issues that are causing you frustration or pain, for example relationship anxiety, work-related pressures, or having too many simultaneous commitments, is a step in effectively dealing with those stress factors. By getting to the root of those specific problems, you can literally dismantle the stress that you experience bit by bit. Then you'll have the freedom to concentrate on cleansing your space and person of the destructive energy and feel your body and mind truly relax. Begin that relaxation process in honor of National Relaxation Day and every day!

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Facts

A person experiencing continual stress is more likely to smoke cigarettes, consume more than a casual amount of alcohol, overeat, or commit suicide. Stress also can be a significant factor in the development of heart disease, high blood pressure, strokes, and have negative impact on the immune system.

Kinesiology Tape... What is it, what does it do and how does it do it?

The Kinesiology Tape is most commonly used in the acute stage of rehabilitation. Correctional techniques include mechanical, lymphatic, ligament / tendon, fascia, space, and functional. Kinesiology Tape can be used in conjunction with other therapies, including cryotherapy, hydrotherapy, massage therapy, and electrical stimulation. Kinesiology Tape affects the activation of neurological and circulatory systems. Your Ad Here The effect of Kinesiology Tape 1. Normalize Muscle Functions. It treats muscle pain due to overuse and troubles. The stressed muscles return to initial state from shoulder pain caused by holding heavy things, calf pain caused by walking too much, whole body pain due to long time exercise, cramp, etc. 2. Increase Circulation of Blood, Lymph, and Tissue Liquid. Itfs normally called bad blood circulation and examples are treating shoulder stiff and cold feeling disorder. When circulation of blood and lymph goes bad, it sticks to one place and as it becomes clot, it starts to put pressure on nerves. Through taping, it gives space between skin and organs which helps circulation and improve all kinds of illnesses. 3. Reduce Pain It stimulus skin and muscle which reduces neurologically. By nature, people themselves have function for reducing pain and it activates by attaching this tape. 4. Prevent from runoff of Articulation. When muscles pulls bone due to abnormal stress, articulation might run off By pasting the tape, movement of muscles goes normal state and it prevent from runoff of articulation.

St Johns Wort shows hope for West Nile

None of the information below has been verified

West Nile Virus, although new to the U.S., is well documented. The Centers for Disease Controlidentifies it as a flavivirus, a member of the Toga virus family. It is closely related to yellow fever and dengue fever. This is important because the Toga virus family are encapsulated viruses,i.e., they are covered with a lipid (fatty)coating.

This is exciting, because it means the virus isaccessible to treatment utilizing high quality St.John’s Wort (SJW). Several studies have been doneon a variety of encapsulated viruses, includingherpes simplex virus types 1 and 2, parainfluenzavirus, vaccinia virus, cytomegalovirus and severalretroviruses including HIV1, 2, 3, 4, 8, 9, 10.

Non-encapsulated viruses or “naked” viruses werealso studied for comparison purposes10,13.

SJW was a potent anti-viral agent across a variety ofencapsulated virus families, but showed noactivity against naked viruses.

Unlike a vaccine that is specific to eachorganism, SJW is active against encapsulated viruses by a variety of mechanisms, including light activation, interference with DNA transcription, impairing the assembly of intactviral particles and the lipophilic (fat-loving)nature of the ring structures (the quinone andphenolic groups)4, 6, 7, 9, 11, 12, 13, 14, 15. These ring structures are critical to the biologic activity of SJW.

From these results, it is reasonable to use highquality, pharmaceutical grade SJW in combatingWest Nile Virus, since there are no effective pharmaceutical agents.

Quality is critical since the level of hypericin and pseudohypericin arekey. I can only recommend the SJW product produced by Medi-Herb, which is a pharmaceutical house in Australia, adhering to pharmaceutical manufacturing standards. The product isdistributed by Standard Process through alternative health care practitioners, including doctors of chiropractic, acupuncturists and veterinarians. SJW is quite unstable and theactive ingredients degrade on store shelves. An independent analysis of 3 products (all of whichwere certified to contain 0.3% hypericin) wereshown to be widely variant, with one product 25%below label claims. It is critically important that the phytochemical integrity of the wholeplant be preserved for maximum efficacy.16

References:1Andersen DO, Weber ND, Wood SG et al. AntiviralRes 1991; 16(2): 185-196.2Lopez-Bazzocchi I, Hudson JB, Towers GHN.Photochem.Photopbiol. 1991; 54(1): 95-98.3Moraleda G, Wu TT, Jilbert AR et al. AntiviralRes 1993; 20: 235-247.4Tang J, Colacino JM, Larsen SH et al. AntiviralRes 1990; 13 (6): 313-325.5Hudson JB, Harris L, Towers GHN. Antiviral Res1993; 20 (2):173-178.6Lenard J, Rabson A, Vanderoef R. Proc Natl AcadSci USA 1993; 90 (1): 158-162.7Degar S, Prince AM, Pascual D et al. AIDS Res HumRetroviruses 1992; 8 (11): 1929-1936.8Carpenter S, Kraus GA. Photochem Photobiol 1991;53 (2): 169-174.9Lavie G, Valentine F, Levin B et al. Proc NatlAcad Sci USA 1989; 86 (15): 5963-5967.10Meruelo D, Lavie G, Lavie D et al. Proc NatlAcad Sci USA 1988; 85 (14): 5230-5234.11Kraus GA, Pratt D, Tossberg J et al. BiochemBiophys Res Commun 1990; 172 (1): 149-153.12Takahashi I, Nakanishi S, Kobayashi E et al.Biochem Biophys Res Commun 1989; 165 (3):1207-1212.13De Witte P, Agostinis P, Van Lint J et al.Biochem Pharmacol 1993; 46 (11): 1929-1936.14Panossian AG, Gabrielian E, Manvelian V et al.Phytomed 1996; 3 (1): 19-28.15Lavie G, Mazur Y, Lavie D et al. Transfusion1995; 35 (5): 392-400.16Constantine GH, Karchesy J. Variations inHypericin concentrations in Hypericum perforatum L. and commercial products. PharmaceuticalBiology 1998; 36 (5): 365-367.