An anisocoria that does not look right
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IMAGING IN INTENSIVE CARE MEDICINE
An anisocoria that does not look right Anastasia Saade*, Jean‑Jacques Tudesq, Guillaume Dumas and Eric Mariotte © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
A 27-year-old man was admitted to the intensive care unit (ICU) for septic shock secondary to right upper lobe community-acquired pneumonia. Neurological exam was normal. ICU stay was complicated by severe acute respiratory distress syndrome requiring invasive mechanical ventilation. Extubation after sedation discontinuation occurred at day 5. Neurological revaluation at day 6 revealed anisocoria with right miosis and ptosis associated with left mydriasis, eyelid retraction and exophtalmia (Fig. 1). A right Claude Bernard–Horner syndrome (CBHS) was suspected. Brain computed tomography did not reveal intracranial pathology. Cervico-thoracic computed tomography showed pneumonia improvement, ruling out a Pancoast–Tobias-like syndrome. Anterior to the left carotid, a hypodense area suggestive of neck hematoma was identified and ascribed to failed left jugular central venous catheter (CVC) insertion attempt at admission (Fig. 2). The close relationship of the hematoma with
Fig. 2 Cervical computed tomography performed at day 6. Arrows delimitate an hypodense area anterior to the left carotid suggestive of an hematoma
the left carotid plexus raised the suspicion of Pourfour du Petit Syndrome (PPS). Ophthalmologic examination suggested left pupillary defect caused by sympathetic nerve stimulation. PPS is a rare entity and appears as a reversed CBHS, resulting from an excitatory lesion of the cervical sympathetic nervous system. PPS should be considered in cases of anisocoria after jugular CVC insertion attempt in the ICU. PPS improved within 2 days, the patient being discharged the day after. Fig. 1 Patient’s photography showing left Pourfour du Petit Syn‑ drome
*Correspondence: [email protected] Medical ICU, APHP, Saint-Louis University Hospital, Paris, France
Funding No funding or financial support was received. Compliance with ethical standards Conflicts of interest The authors declare that they have no conflict of interest in relation to this work. Informed consent The patient gave written consent for publication.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub‑ lished maps and institutional affiliations. Received: 16 January 2020 Accepted: 16 March 2020
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