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- Frederick Bassal, DO*
- Pamela Lupo, MD†
- *Department of Pediatrics, University of Texas Medical Branch, Galveston, TX
- †Department of Pediatrics, Neurology Division, University of Texas Medical Branch, Galveston, TX
AUTHOR DISCLOSURE
Drs Bassal and Lupo have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
Presentation
A previously healthy 11-year-old boy is admitted to the hospital for 2 days of new-onset blurry vision, diplopia, and unsteady gait. He denies recent trauma, dizziness, weakness, headaches, nausea, vomiting, diarrhea, fever, and travel. The patient denies recent ingestion of alcohol, illicit drugs, medications, or toxins. Further questioning reveals a 1-day history of coughing, sneezing, and watery eye discharge occurring 1 week earlier that seemingly improved after antihistamine use.
On admission, his vital signs are as follows: temperature, 98.5°F (36.9°C); pulse, 83 beats/min; respiratory rate, 18 breaths/min; blood pressure, 129/86 mm Hg; and oxygen saturation, 100% in room air. Physical examination reveals a well-nourished boy with appropriate affect and mentation. Ophthalmologic examination is significant for left esotropia and mild bilateral hypertropia. Extraocular movements are painless, with incomplete abduction of both eyes, worse on the left. Consensual pupillary response is absent, and the pupils are dilated to 7 mm at baseline, with a sluggish direct response to light. There is no optic nerve edema. Neurologic examination is otherwise significant for dysmetria, which improves somewhat with covering 1 eye, and a tentative gait with unsteadiness concerning for gait ataxia. Reflexes are difficult to elicit but present, and there is no …
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