Kumari Madhulata, Uzma Jawaid, Rishi Tarafdar, Shreya Khandelwal
This case illustrates a rare and severe multisystem presentation of RA, complicated by disseminated infection and CST. It emphasizes the need for heightened clinical vigilance, early neuroimaging, and an integrated therapeutic approach when patients with autoimmune disease present with painful ophthalmoplegia and neurological deficits to prevent potentially fatal outcomes.
INTRODUCTION: Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease primarily affecting synovial joints, but it may also manifest with extra-articular involvement, including neurological and ophthalmic complications. Cavernous sinus thrombosis (CST) is a rare yet life-threatening condition, most often secondary to infection, characterized by painful ophthalmoplegia, proptosis, and cranial nerve dysfunction. The coexistence of RA, disseminated infection, and CST is exceedingly uncommon and presents significant diagnostic and therapeutic challenges. This case highlights the importance of early recognition of atypical ophthalmic and neurological manifestations in patients with autoimmune disease.
CASE PRESENTATION: A diabetic patient with a 6-month history of progressive symmetrical polyarthralgia, joint swelling, deformities, and upper motor neuron signs presented with acute right-sided painful ophthalmoplegia and proptosis. Clinical evaluation revealed seropositive RA with elevated inflammatory markers and leukocytosis. A neuro-ophthalmic examination demonstrated chemosis, sixth cranial nerve palsy, and raised intraocular pressure. Magnetic resonance imaging of the brain and orbits revealed bilateral superior ophthalmic vein thrombosis, cavernous sinus involvement, multiple intracranial and deep facial space abscesses, and cervicomedullary junction compression, consistent with disseminated infection and septic emboli.
CLINICAL DISCUSSION: This case underscores the diagnostic complexity arising from overlapping autoimmune and infectious processes. Immune dysregulation associated with RA and diabetes likely predisposed the patient to disseminated infection and secondary venous thrombosis. Early ophthalmic signs served as critical diagnostic clues, while magnetic resonance imaging was instrumental in identifying the extent of multisystem involvement. Prompt initiation of broad-spectrum antibiotics, systemic corticosteroids, anticoagulation, and multidisciplinary management resulted in significant clinical improvement.
CONCLUSION: This case illustrates a rare and severe multisystem presentation of RA, complicated by disseminated infection and CST. It emphasizes the need for heightened clinical vigilance, early neuroimaging, and an integrated therapeutic approach when patients with autoimmune disease present with painful ophthalmoplegia and neurological deficits to prevent potentially fatal outcomes.