Cranial nerve palsy in diabetes: 'Hunt' for the diagnosis

A 55-year-old diabetic woman presenting with right sixth nerve palsy was diagnosed initially as having diabetic cranial neuropathy. Worsening headache and reported blurring of the right optic disc margin warranted further evaluation. CT scan of the brain was normal and a diagnosis of idiopathic intracranial hypertension was made. Her headache worsened and a partial pupil involving third nerve palsy evolved, at which point she was referred to our institution. Cranial MRI revealed features suggestive of Tolosa-Hunt syndrome and she responded dramatically to steroid therapy. While third nerve palsy is the most common cranial neuropathy in diabetic patients, sixth nerve palsy merits a wide array of differential diagnoses. A gadolinium-enhanced MRI of the brain is the preferred imaging modality for evaluating such patients, before branding them as having diabetic cranial neuropathy. Copyright (C) 2013 John Wiley & Sons.