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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 51, Num. 2, 2003, pp. 289

Neurology India, Vol. 51, No. 2, April-June, 2003, pp. 289

Letter to Editor

Cavernous sinus syndrome due to syphilitic pachymeningitis

D. B. Nadgir, R. Ramdas, R. V. Kulkarni, P. J. Oak, A. B. Shah
Department of Neurology, TNMC and B Y L Nair Ch. Hospital Mumbai, Mumbai Central, Mumbai-400008.

Accepted on 10.05.2002.

Code Number: ni03098


Anterior cavernous sinus syndrome has various etiologies1 like infections, inflammation, cavernous sinus thrombosis, carotid cavernous fistula and compression. Syphilitic pachymeningitis has been reported earlier, presenting as multiple cranial nerve involvement2,3 or paraparesis.4

A 50-year-old taxi driver with a history of multiple unprotected sexual exposures presented with 3 months history of right frontotemporal headache and diplopia of 2 weeks duration. His general and systemic examination was unremarkable. Central nervous system examination showed evidence of right-sided complete ophthalmoplegia. In addition, there was numbness in the distribution of the first division of the trigeminal nerve. He had no evidence of long tract involvement. Routine investigations including hemogram (ESR 24), chest X-ray and blood biochemistry were normal. MRI brain showed dural-based enhancing bulky soft tissue lesion with thickening of tentorial leaves in the right cavernous sinus extending up to the medial aspect of the right temporal lobe. Cerebrospinal fluid (CSF) examination revealed neutrophilic pleocytosis (15 nucleated cells with 60% polymorphs) with normal sugar and protein. Serum VDRL was positive (1:64 dilution) with positive TPHA. CSF VDRL was also positive in significant titre. In view of MRI features of pachymeningitis and positive tests for syphilis, the patient was treated with injection crystalline penicillin (4 million units 4 hourly for 14 days). Following standard treatment regimen for neurosyphilis the patient showed complete clinical recovery with resolution of the dural-based cavernous sinus lesion on follow-up MRI.

This case highlights MRI features in syphilitic pachymeningitis.


1. Thomos M Bosley, Norman J Schatz. Cdiagnosis of cavernous sinus syndrome. Neurologic Clinics 1983:14:929-49.
2. Komachi H. Skeda M, et al. Case of syphilitic meningitis presenting as seventh and eight nerve palsies, No To Shinkei 1990;42:651-4.
3. Currie JN, Coppeto JR, et al. Chronic syphilitic meningitis resulting in superior orbital fissure syndrome and posterior fossa gumma, A report of 2 cases followed for 20 years. J Clin Neuroopathalmol 1988:8:145.
4. Deshpande DH, Vidyasagar C. Hypertrophic pachymeningitis dorsalis. Surg Neurol 1979:12:217-20.

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