An anisocoria that does not look right

A 27-year-old man was admitted to the intensive care unit (ICU) for septic shock secondary to right upper lobe community-acquired pneumonia. Neurological exam was normal. ICU stay was complicated by severe acute respiratory distress syndrome requiring invasive mechanical ventilation.

Extubation after sedation discontinuation occurred at day 5. Neurological revaluation at day 6 revealed anisocoria with right miosis and ptosis associated with left mydriasis, eyelid retraction and exophtalmia (Fig. 1). A right Claude Bernard–Horner syndrome (CBHS) was suspected. Brain computed tomography did not reveal intracranial pathology. Cervico-thoracic computed tomography showed pneumonia improvement, ruling out a Pancoast–Tobias-like syndrome. Anterior to the left carotid, a hypodense area suggestive of neck hematoma was identified and ascribed to failed left jugular central venous catheter (CVC) insertion attempt at admission (Fig. 2). The close relationship of the hematoma with the left carotid plexus raised the suspicion of Pourfour du Petit Syndrome (PPS). Ophthalmologic examination suggested left pupillary defect caused by sympathetic nerve stimulation.

Fig. 1

Patient’s photography showing left Pourfour du Petit Syndrome

Fig. 2

Cervical computed tomography performed at day 6.  Arrows delimitate an hypodense area anterior to the left carotid suggestive of an hematoma

PPS is a rare entity and appears as a reversed CBHS, resulting from an excitatory lesion of the cervical sympathetic nervous system. PPS should be considered in cases of anisocoria after jugular CVC insertion attempt in the ICU. PPS improved within 2 days, the patient being discharged the day after.


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Correspondence to Anastasia Saade.

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Saade, A., Tudesq, J., Dumas, G. et al. An anisocoria that does not look right. Intensive Care Med (2020).

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