Rhomboencephalitis due to cocaine-induced bony erosion of skull base
Citation Manager Formats
Make Comment
See Comments

A 49-year-old man with 10 years of intranasal cocaine use presented with dysphagia. Neurologic examination demonstrated bilateral sixth nerve palsies. Brain MRI showed erosion of the sphenoid sinus walls and a defect in the skull base; the resulting path between the nasal cavity and brainstem permitted rhomboencephalitis and clival osteomyelitis (figure 1). Clival cultures grew methicillin-resistant Staphylococcus aureus. IV antibiotics were administered and switched to oral after 6 weeks. Repeat MRI showed decreased T2 fluid-attenuated inversion recovery brainstem hyperintensity (figure 2). Antibiotics will be used for at least 1 year; surgical reconstruction of the skull base will depend on his abstinence from cocaine.
Sagittal T2 (A), axial T2 fluid-attenuated inversion recovery (B), and sagittal T1 with contrast MRI (C) show a large bony defect in the skull base with erosion of the sphenoid sinus walls and perforated nasal septum. There is abnormal T2 hyperintensity and enhancement in the brainstem with clival erosion (arrow where most severe) and marrow enhancement.
Axial T2 fluid-attenuated inversion recovery MRI of the brain demonstrates decreased T2 fluid-attenuated inversion recovery hyperintensity in the medulla following 6 weeks of IV antibiotics.
Footnotes
-
Author contributions: Jordan S. Dubow: involved in conceptualization of paper and drafting the manuscript. Samuel Singer: involved in revising the manuscript. Alan Z. Segal: involved in revising the manuscript.
-
Disclosure: Dr. Dubow and Dr. Singer report no disclosures. Dr. Segal serves on the speakers' bureau for Boehringer Ingelheim.
- Copyright © 2011 by AAN Enterprises, Inc.
Letters: Rapid online correspondence
REQUIREMENTS
You must ensure that your Disclosures have been updated within the previous six months. Please go to our Submission Site to add or update your Disclosure information.
Your co-authors must send a completed Publishing Agreement Form to Neurology Staff (not necessary for the lead/corresponding author as the form below will suffice) before you upload your comment.
If you are responding to a comment that was written about an article you originally authored:
You (and co-authors) do not need to fill out forms or check disclosures as author forms are still valid
and apply to letter.
Submission specifications:
- Submissions must be < 200 words with < 5 references. Reference 1 must be the article on which you are commenting.
- Submissions should not have more than 5 authors. (Exception: original author replies can include all original authors of the article)
- Submit only on articles published within 6 months of issue date.
- Do not be redundant. Read any comments already posted on the article prior to submission.
- Submitted comments are subject to editing and editor review prior to posting.
You May Also be Interested in
Dr. Nicole Sur and Dr. Mausaminben Hathidara
► Watch
Related Articles
- No related articles found.
Topics Discussed
Alert Me
Recommended articles
-
Articles
Intracranial arterial wall imaging using high-resolution 3-tesla contrast-enhanced MRIR. H. Swartz, S. S. Bhuta, R. I. Farb et al.Neurology, February 16, 2009 -
Resident and Fellow Section
Clinical Reasoning: An unusual cause of transverse myelitis?Pavan Bhargava, Rodger J. Elble et al.Neurology, February 10, 2014 -
Resident and Fellow Section
Clinical Reasoning: A young woman with respiratory failure, hearing loss, and paraplegiaAchilles Ntranos, Hazem Shoirah, Mandip S. Dhamoon et al.Neurology, March 06, 2017 -
Resident & Fellow Section
Teaching NeuroImages: Transient mutism associated with splenium lesion in capecitabine-induced leukoencephalopathyTommaso Nicoletti, Gregorio Spagni, Marco Luigetti et al.Neurology, February 25, 2019