A 30-year-old woman with a remote history of Hemophilus influenzae type b meningitis causing quadraparesis was admitted to the hospital with Candida fungemia. In the hospital, it was noticed that she had alternating ptosis and miosis, and neurology was consulted for query central nervous system Candida infection. However, she reported a history of intermittent eyelid drooping for at least the last year, and her mother noted alternating pupillary asymmetry for many years. She had no headaches. On examination, vital signs did not reveal any dysautonomia. There was right-sided ptosis and miosis, with greater anisocoria in dim light and right pupillary dilation lag compatible with a right-sided Horner syndrome (Figure, A). Profuse sweating of the left face was also observed. Cranial nerve examination was otherwise unremarkable. Weakness of all 4 extremities was found, more so on the right than left, with increased tone and hyperreflexia indicating a spastic quadraparesis. Sensory testing was normal in all 4 extremities. Later that day, the patient had a left-sided Horner syndrome (Figure, B). Her Horner syndrome alternated at least twice a day without provocation. Contralateral facial hemihyperhidrosis was repeatedly observed with the right-sided Horner syndrome (Figure, C) but not the left-sided Horner syndrome. Magnetic resonance imaging of the brain and cervicothoracic spine revealed focal atrophy of the lower medulla, more prominent on the right than the left, as well as of the upper cervical cord, most likely from remote basilar meningitis (Figure, D-F). Symmetric parietal and cerebellar encephalomalacia was seen as well, in addition to likely sequelae of her prior meningitis. Her clinical presentation was most referable to remote cervicomedullary injury rather than acute central nervous system infection, mitigating the need for any further in-hospital investigations.
Budhram A, Feng M, Mather R, Lee DH, Moulin DE. Alternating Horner Syndrome With Vegetative Alterna and Spastic Quadraparesis After Bacterial Meningitis. JAMA Neurol. 2017;74(12):1504–1506. doi:10.1001/jamaneurol.2017.2865
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