The case involves a 53-year-old man who, in October 2006, presented with symptoms including a throbbing headache, discomfort in the left frontal region of the head, and diplopia in all directions. However, by January 2007, his condition had improved without treatment. In March 2008, the patient developed diplopia and fatigability. In April, visual field defects and visual loss became evident. His vision impairment progressively worsened, and when he first visited our hospital in January 2009, he was found to have light perception vision in the right eye and hand motion vision in the left eye. A contrast brain magnetic resonance imaging (MRI) scan revealed diffuse thickening of the dura mater.
At the age of 23, the patient received a subtotal gastrectomy to treat a gastric ulcer. The patient had no noteworthy family history.
The patient’s body temperature was 36.4°C. Upon examination, he exhibited mild clouding of consciousness and some cranial nerve problems including impaired sense of smell in both nostrils, binocular blindness, ptosis, restricted eye movement in all directions, round pupils, reduced reaction to light, and numbness in the first branch of the left trigeminal nerve. His deep tendon reflex was normal without any pathological reflexes. No other neurological abnormalities were noted. The patient was able to walk without assistance.
The erythrocyte sedimentation rate (ESR) was 57 mm/h (normal <7), C reactive protein (CRP) was 3.82 mg/dl (normal <0.2), rheumatoid factor (RF) was 38 U/ml (normal <18), MMP-3 (latex agglutination immunoassay method) was 148 ng/ml (normal range 36.9–121), and the anti-cyclic citrullinated peptide (anti-CCP) antibodies were <0.6 U/ml (normal <4).
The patient tested negative for the following antibodies: antinuclear antibody, anti-DNA antibody, anti-SS-A/SS-B antibody, anti-myeloperoxidase ANCA, and anti-proteinase-3 ANCA.
The angiotensin converting enzyme value was within normal range.
An examination of the cerebrospinal fluid revealed the following results: initial pressure >220 mm H2O, mononuclear cells 5/mm3, protein 94 mg/dl (normal <40), glucose 75 mg/dl (non-fasting glucose 116 mg/dl), and culture negative for bacteria and acidophiles.