|Year : 1968 | Volume
| Issue : 2 | Page : 85-88
JS Gupta, Kapalmit Singh, SD Gupta
Department of Ophthalmology, Institute of Post Graduate Medical Education and Research, Chandigarh, India
J S Gupta
Department of Ophthalmology, Institute of Post Graduate Medical Education and Research, Chandigarh
|How to cite this article:|
Gupta J S, Singh K, Gupta S D. Proptosis migrans. Indian J Ophthalmol 1968;16:85-8
Thrombophlebitis migrans was first described by Fremy (1804). Since then extensive literature has accumulated on the various facets of the problem. The case presented here unusual and as far as we could scan the literature such a clinical picture has never been described before, because the proptosis encountered in this case was of a migrating type. The name proptosis-migrans has been coined for this condition.
| Case history|| |
Patient G. S. 56 years male, a medical practitioner was admitted to the Post-Graduate Institute Hospital on 17.1-1966 with the history of pain in the left leg and calf muscles from 15.12.1966. This was followed by pitting oedema and painful red swelling in the same region. Walking was difficult due to the severity of pain. The trouble subsided in a week's time with rest.
One week after this episode, he developed a hard nodular swelling on the right cheek close to the angle of the mouth accompanied by mild fever occasional vomiting and dry cough. The pain in the nodule was intense, so much so that eating was not possible for a few days. In two days' time the swelling extended to the right side of the face and the right eye ball became prominent. The right side of the face showed swelling which was red and tender. The headache was severe. At this time the patient was admitted in a provincial hospital and was labelled as a case of orbital cellutitis. He was put on heavy doses of antibiotics and cortico-steroids. The condition subsided in a week's time. While the swelling on the right side was decreasing he developed a painful nodule on the left side of the angle of the mouth. This also extended towards the lids involving the orbit leading to proptosis of the left eye. At this stage he was admitted to our Hospital. In the past history nothing significant was elicited. He was found to be very ill, slightly anemic with a blood pressure of 125/80. There was no evident abnormality detectable in the general examination.
On local examination, the right eye revealed slight superficial conjunctival congestion, with pseudo-pterygium formation in the lower part of the cornea. The pupil, fundus, and vision were within normal limits.
The left side had marked swollen lids, reddish in colour and tender to touch. The eyeball was markedly proptosed, the conjunctiva showed so much chemosis that it was protruding through the palpebral aperture. The cornea was exposed but was clear with unimpaired sensitivity. The pupil had normal reaction and the vision was satisfactory. Ocular movements were limited in all directions.
Considering the good pupillary response with good vision, and the past history he was diagnosed as a case of thrombo-phlebitis-migrans where one eye was involved first and now the second eye was being involved. In two days time the left cornea got ulcerated in the lower part. Tarsorrhaphy was not possible and so only a padded ring with a shield was used to prevent exposure. He was put on anticoagulant (Syntrom) and antibiotic therapy.
On 22nd January, (five days after admission) he developed pain in both calves and they were found to be swollen and tender. Next day some oedema was noticed on the left ankle. In addition a small painful swelling was also noticed on his left forearm. On 24th the swelling of the eye ball was noticed to have considerably decreased [Figure - 2]. Also there was regression in the swelling of the ankle and lower third of leg on the left side. In four days time the condition of the left leg and eye had considerably improved. The fundus was normal.
On 30th January pain reappeared in both calves and there was a cord like tender swelling noticed along the course of a vein on one side. This increased the oedema upto the knees in 3 days time. At this time three tender nodules were noted on the right forearm. These were situated along a vein. These appeared to be subcutaneous ha matomas which regressed in a few days time.
On 14th Feb., he developed another similar swelling on the right forearm. The condition of the left eye at this time was normal and a pseudopterygium formation had resulted akin to the right eye condition. Subsequently the patient was discharged on request.
On 27th March, he was readmitted with pain in the right shoulder region and pain around the right eye. At either site, pain was diffuse and non-radiating. On examination there was generalised oedema of the right upper and lower lids, the upper one being more marked than the lower. [Figure - 3]. The swelling was tender and the skin dusky red in colour. Conjunctiva was oedematous all over and the eye ball was slightly prominent. Cornea was clear with unimpaired sensation [Figure - 4]. Rest of the ocular examination was normal. Eye movements were slightly restricted in all directions but it was more so in the upward direction. Involvement of the right eye had occured at the onset, about three months back, but this time it subsided in three days time and was much less in severity. At this stage the liver was found to be enlarged by 4 cm. and the right diaphragm was raised with a few linear opacities at the base of the right lung.
Subsequently nothing untoward happened except the appearance and disappearance of nodules, till on 16th July he developed a painful nodule in the abdominal wall. On 26th July he got proptosis of he left eye with conjunctival chemosis [Figure - 5]. These got subsided, till on 25th July he was discharged on request. He had lost a lot of weight and was also cachectic and the time of discharge. No supporting measures helped him regain weight.
Nothing abnormal was detected in his urine and stools. Electrocardiogram and liver function tests were normal.
Blood examination showed a low R.B.C. count (3.3 million/c mm), hemoglobin 9.2 gms per cent and anisocytosis. The only other abnormality was a low packed cell volume (29 per cent).
Serum for acid and alkaline phosphatase was normal (0.50 and 9.3 B. V. respectively).
Blood urea (33 mg per cent) and blood sugar (fasting 120 mg per cent) were within normal limits. Blood for lupus ecrythematosus cells was negative. Capillary fragility was normal and the blood culture was sterile.
X-ray examination of the chest, abdomen and forearms and barium meal study of the stomach and duodenum brought out no abnormality. Oral cholecystography showed concentration of the dye after a fatty meal.
Nodule biopsy showed absence of veins. There was inflammatory scarring in muscular layer with chronic myositis.
| Resume|| |
This patient of thrombophlebitis migrans presented with the interesting ophthalmological picture of recurring and migrating proptosis. This proptosis first appeared on right side on 24.12-65 and then on left side on 13.1.1966. Again it recurred on right side on 27.3.66 and later towards left side on 26.6.66. Each time it subsided of its own.
| Comments|| |
Thrombophlebitis migrans is usually taken as an evidence of some visceral malignancy. It has been reported in association with carcinoma pancreas, stomach, breast, lung, and gall bladder. Whatever investigations were done on this case have not revealed any malignancy. Though laprotomy has been advised for these occult malignancy cases, this could not be carried out here because of the poor condition of the patient. The deteriorating condition of the patient was almost a positive proof in favour of some malignant process. The interesing feature in this condition as reported by Martin et al (1953) is, that even following surgical treatment of a detected malignancy, the patient is not free from attacks of phlebitis. Emboli of malignant cells are suggested as a cause of phlebitis by (Williams 1954) but one wonders why these emboli could not have made their appearance in the choroid inspite of repeated proptosis and why the emboli disappeared instead of proliferating at the lodged sites. It is also noteworthy that these attacks could not be controlled by anticoagulants which would indicate that alteration in the composition of blood is not an important feature (Williams 1954). This is also illustrated in this case where though the patient was always on an anticoagulant therapy, there were recurrent attacks even during the therapy. Cultures from the veins were sterile. Release of ferments in pancreas tumours is blamed for this condition. (Martin et al 1956). The cause of this disease remains obscure. It is rather difficult to explain the production of such a migrating type of proptosis. It is possible that cases of allergic proptosis with no general trouble so far described may turn out to be one of this type on a long follow up.
| Summary|| |
A case of thrombophlebitis miggrans has been described. The interesting ophthalmic feature of this case was the recurrent migrating type of proptosis. It occurred twice in each eye and subsided automatically without leaving any visual damage. No cause could be found out. Malignant emboli as a cause of this process does not seen tenable. It is possible that some unknown toxic products released from the malignant site might be responsible for this process to occur.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]