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Unusual association of diseases/symptoms
Case report
Bilateral, vertical supranuclear gaze palsy following unilateral midbrain infarct
  1. Yunfei Yang1,
  2. Umair Qidwai2,
  3. Benjamin J L Burton2 and
  4. Carlo Canepa2
  1. 1Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  2. 2James Paget University Hospital, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
  1. Correspondence to Dr Yunfei Yang; yunfei.yang{at}nhs.net

Abstract

A 60-year-old man recently admitted for bipedal oedema, endocarditis and a persistently positive COVID-19 swab with a history of anticoagulation on rivaroxaban for atrial fibrillation, transitional cell carcinoma, cerebral amyloid angiopathy, diabetes and hypertension presented with sudden onset diplopia and vertical gaze palsy. Vestibulo-ocular reflex was preserved. Simultaneously, he developed a scotoma and sudden visual loss, and was found to have a right branch retinal artery occlusion. MRI head demonstrated a unilateral midbrain infarct. This case demonstrates a rare unilateral cause of bilateral supranuclear palsy which spares the posterior commisure. The case also raises a question about the contribution of COVID-19 to the procoagulant status of the patient which already includes atrial fibrillation and endocarditis, and presents a complex treatment dilemma regarding anticoagulation.

  • neuroopthalmology
  • stroke
  • visual pathway
  • contraindications and precautions
  • TB and other respiratory infections

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

https://doi.org/10.1136/bcr-2020-238422

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    Footnotes

    • Contributors YY and CC composed the first draft of the manuscript. BJLB and UQ reviewed and edited the manuscript and reviewed the patient in the clinic for disc imaging and follow-up for the retinal artery occlusion. CC conceived the project, was involved in the direct patient contact, history-taking and consent for the project. CC created figure 3 as an original image. All authors reviewed and gave final approval of the version to be published.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Obtained.

    • Provenance and peer review Not commissioned; externally peer-reviewed.