Headache, Ophthalmoplegia, “Mirror Pattern Bands”: Two Case Reports

Tolosa-Hunt syndrome (THS) is an idiopathic, granulomatous inflammation in the cavernous sinus, supraorbital fissure or orbit. Although the pathophysiology of this idiopathic granulomatous inflammatory process is not clear, it has been suggested that cerebrospinal fluid (CSF) analyses could be helpful in understanding the underlying mechanisms. We report two cases of the 3rd Edition of the International Classification of Headache Disorders (ICHD-3)-classified THS who presented with headache and diplopia. After early treatment with intravenous methylprednisolone, the symptoms of two patients were significantly improved. On outpatient follow-up, neither patient had a relapse. It is worth noting that the isoelectric focusing showed identical CSF and serum oligoclonal IgG bands (OBs). Such bands, “mirror pattern bands”, are one of five standardized patterns (i.e., type 1 = absence of bands in serum and CSF; type 2 = presence of OBs in CSF; type 3 = presence of OBs in CSF and additional identical OBs in both serum and CSF, indicative of intrathecal synthesis; type 4 = presence of identical OBs in both serum and CSF, “mirror pattern”; and type 5 = presence of a monoclonal band in serum and CSF). Previous studies have only found OBs in the CSF of THS (type 4). The finding of “mirror pattern bands” is interesting as it reveals an underlying possible systemic immune activation mechanism in THS.