Transient congenital Horner syndrome and multiple peripheral nerve injury: a scarcely reported combination in birth trauma

Abstract Objectives To describe an infrequent association of multiple injuries in relation to perinatal trauma and the challenge of clinical examination for proper diagnosis. Case presentation A male newborn was born at 41 weeks gestational age to a multipara diabetic mother, by forceps. Apgar 8/9. Upon admission, he exhibited axial hypotonia, right brachial paresis, a large left parietal cephalohematoma, but no skull fractures or orbital injuries. He also showed ocular misalignment with marked esotropia of the right eye, ptosis and mild anisocoria, suggesting right Horner syndrome, and left facial palsy. During the oculo-cephalic reflex examination he exhibited a normal adduction and impaired abduction of the right eye. The cranial MRI showed an extensive left parietal cephalohematoma, with internal foci of recent bleeding, and supra and infratentorial laminar subdural hematomas. No lesions were evidenced in the cavernous sinuses. The recovery of extra and intraocular motility at one month of life in our patient highlighted the transitory nature of the lesions and was reassuring for the parents. Conclusions This case highlights the importance of a detailed clinical examination in the initial evaluation of a newborn at neurological risk after birth trauma. The association of sixth cranial nerve palsy, Horner syndrome, facial palsy, and brachial plexus injury have been scarcely referred in this context and, if not adequately interpreted, might suggest erroneous diagnoses with very different prognoses.