Tolosa-Hunt syndrome and COVID-19: report of a case

Abstract

Objetive: To describe a case of Tolosa-Hunt síndrome (THS) and COVID-19. 
Clinical case: 73-year-old male patient, hypertensive, presenting severe headache and left periorbital pain of ten days of evolution and binocular diplopía of seven days of evolution. Ocular examination revealed exotropia in primary gaze position associated with blepharoptosis and adduction limitation of the left eye, isochoric pupils, preserved photomotor and consensual reflexes, findings compatible with incomplete pupil-sparing left third cranial nerve palsy. Laboratory exams were normal, except RT-PCR for SARS-CoV-2 which was positive. Brain and orbits MRI revealed a subtle asymmetric enhancement in the anterior cavernous sinus, superior orbital fissure and orbital ápex. Oral corticosteroid therapy was started obtaining good response. 
Conclusion: Defining THS among the numerous causes of painful ophthalmoplegia is a diagnostic challenge and the most frequent causes —some of them more severe— must be ruled out. Given the current pandemic situation and considering the different clinical manifestation associated with COVID-19, the study of this disorder must include SARS-CoV-2 infection as well as history of vaccination against it to further clarify potential post-infectious or autoimmune phenomena.