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Correspondence to Dr Simon Biart, [email protected]
Background
We present a case of skull base osteomyelitis presenting with headache, a left-sided Horner’s syndrome, and a partial sixth nerve palsy. This case is of interest due to its rarity and the diagnostic challenge it represented to the medical team.
Case presentation
An 88-year-old woman presented with a 4-week history of worsening left-sided headache and diplopia on leftwards gaze.
The prior medical history was of atrial fibrillation, chronic kidney disease, an old left-sided ischaemic stroke and a spontaneous, minor left-sided parietal intracerebral haemorrhage while on anticoagulation. Her regular medications were furosemide, apixaban, paracetamol and oxycodone for back pain.
Of note in the previous 6 months, she had been treated for suspected left-sided giant cell arteritis and had seen her general practitioner (GP) and an ear nose and throat (ENT) specialist for a slowly resolving pseudomonal left middle ear infection.
On examination, the patient was systemically well. She had a left-sided ptosis and miosis in addition to diplopia provoked with leftwards gaze. Important negative findings included a lack of nystagmus, intact visual acuity and colour appreciation and an absence of scalp tenderness.
Initial investigation revealed a persistently raised white cell count (WCC), C reactive protein (CRP) and erythrocyte sedimentation rate (ESR) (present since treatment for suspected giant cell arteritis (GCA)) and a normal CT brain. Temporal artery Doppler demonstrated intimal thickening but no arteritis.
After review by rheumatology (given a history of presumed GCA and a left-sided headache), and neurology—the differentials were felt to...