Journal List > J Korean Ophthalmol Soc > v.54(8) > 1009464

Seok, Choi, and Jung: Bilateral Abducens Nerve Palsy in Pediatric Patients with Epstein-Barr Virus Encephalitis

Abstract

Purpose

To report 2 cases that presented with bilateral abducens nerve palsy associated with Epstein-Barr virus (EBV) encephalitis in children.

Case summary

Case 1. A 14-month-old boy presented with fever and esodeviation of the left eye that started 5 days earlier. On the ophthalmic examination, 45-PD esotropia of the left eye and limitation of abduction in both eyes were observed. On neurological examination, there were no abnormalities. Serologic test and polymerase chain reaction (PCR) from cerebrospinal fluid (CSF) were positive for EBV. The patient was treated with systemic acyclovir and prednisolone. Part-time occlusion therapy of the right eye for 2 hours/day was also prescribed. The patient underwent a 6.5-millimeter re-cession of the medial rectus and a 6-millimeter resection of the lateral rectus on the left eye 7 months after the presentation. The patient showed orthotropia 1 week after the surgery without neurologic sequelae. Case 2. A 13-year-old boy presented with headaches and fever that started 5 days before and altered consciousness with seizures 2 days previously. Serological test for viral infection was normal, except for EBV, and CSF examination showed viral infection. After the patient recovered consciousness, he complained of diplopia. A 30-PD esotropia of his left eye with bilateral limi-tation of abduction was present. Alternating full-time occlusion of both eyes was prescribed. At 4 months after pre-sentation, diplopia disappeared and the patient showed orthotropia without abduction limitation; however, anticonvulsants were prescribed to control seizures.

Conclusions

In children, EBV encephalitis can be accompanied by acquired bilateral abducens nerve palsy. Residual nerve palsy and other neurologic sequelae can remain after several months.

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Figure 1.
In Case 1, he showed esodeviation of the left eye at primary gaze position (A). Four months later, there still was esodeviation in the left eye (B). One week after strabismus sur-gery, he showed orthotropia (C).
jkos-54-1303f1.tif
Figure 2.
Brain MRI of case 1. T1 weighted sagittal images show low signal intensity (arrows, A) and T2 weighted axial images show high signal intensity (arrows, B) without en-hancement at anterior portion of pons and medulla.
jkos-54-1303f2.tif
Figure 3.
Brain MRI of case 2. MRI scans reveal high signal in-tensity in the bilateral temporal, frontal, and parietal area in T2 weighted image (arrows, A) and diffusion-weighted image with-out enhancement (arrows, B).
jkos-54-1303f3.tif
Figure 4.
In case 2, there is esodeviation with bilateral limitation of abduction.
jkos-54-1303f4.tif
Figure 5.
Hess screen test revealed esotropia with bilateral abduction limitation in case 2.
jkos-54-1303f5.tif
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