Multiple Sclerosis and other Neurological Conditions
Yusuf Mahmoud, MD
Resident
Hackensack Meridian Health
elmwood park, New Jersey, United States
Shane V. McNamara, MD
Resident Physician
Johnson Rehabilitation Institute at JFK Medical Center
New Brunswick, New Jersey, United States
Jennifer Chui, MD
Spinal Cord Injury Medical Director
JFK Johnson Rehabilitation Insititute
Edison, New Jersey, United States
Yusuf Mahmoud, MD
JFK Johnson Rehabilitation Institute
Elmwood Park, New Jersey, United States
A 25-year-old woman with a history of multiple spinal schwannomas and three prior resections was admitted following a third thoracic tumor removal. During recovery, she developed gradual onset unilateral headache, vision changes, hearing loss, and L sided face and upper extremity numbness, concerning for vestibular schwannoma or metastatic disease. Given her tumor history, anchoring bias initially influenced the differential. However, brain and orbital MRI revealed an orbital abscess. She was treated with intravenous antibiotics and corticosteroids with resolution of symptoms.
Discussions:
This case demonstrates the diagnostic challenges in young patients with underlying tumor syndromes, where new neurological symptoms may be prematurely attributed to tumor progression. Although not formally diagnosed in this case, schwannomatosis is rare in young adults and typically manifests with multiple peripheral and spinal schwannomas as noted in this patients history. The development of gradual unilateral headache and vision, sensory and auditory changes initially raised concern for vestibular schwannoma or metastatic disease, reflecting an anchoring bias toward her presumed underlying condition. However, further imaging demonstrated an orbital abscess, an unrelated but potentially life-threatening infectious process. Orbital abscesses are uncommon and often arise from contiguous sinus disease or hematogenous spread. Delayed recognition can result in vision loss or intracranial complications. This case emphasizes the importance of maintaining a broad differential, even in patients with known complex pathology, and demonstrates how diagnostic vigilance can prevent misattribution of new symptoms.
Conclusions:
This case demonstrates the diagnostic challenges in young patients with underlying tumor syndromes, where new neurological symptoms may be prematurely attributed to tumor progression. This case emphasizes the importance of maintaining a broad differential, even in patients with known complex pathology, and demonstrates how diagnostic vigilance can prevent misattribution of new symptoms.
