複視──神經急症之鑑別診斷思維與病例分享

The Differential Diagnosis for Diplopia to Identify/Exclude Possible Emergency Neurological Diseases: Demonstrations from Two Clinical Cases

複視之表現涵蓋各種嚴重眼科疾病與神經系統重症的可能，需要臨床醫師快速鑑別診斷並應有足夠的認識與警覺。本文整理中西醫之文獻，以釐清複視的西醫鑑別診斷思路與中醫辨證處方用藥原則，並以二例原因不同之複視病例作佐證。第一個病例為有肝癌病史之67歲男性突發複視及頭暈，經轉診急診後，證實其複視為嚴重中樞神經疾病之初期表現，提示臨床應審慎診察不可輕忽；第二個病例為頭痛主訴之48歲男性，最終診斷為疑似第六對腦神經之病毒感染，其診治過程呈現出臨床應有之鑑別診斷思考及如何安排檢驗與檢查來協助診斷，該病例在高劑量類固醇治療無效後，以水煎劑麻黃湯之加減使症狀迅速獲得改善。本文透過文獻整理與病案分析，提供中醫師於臨床上做初步診斷、適當轉介及正確治療之依據。 Diplopia is a possible clinical presentation of some severe ophthalmologic or neurologic diseases. Clinicians should have enough knowledge and awareness to make differential diagnosis as soon as possible when approaching a patient with diplopia. We organized the information about diplopia from Chinese and Western medicine literature to clarify the thinking process of making differential diagnosis and the principles of Traditional Chinese Medicine’s (TCM) pattern identification and treatment. We used two different cases with diplopia to present the differential diagnosis and treatment processes by pattern identification. The first case was a 67-year old male with hepatocellular carcinoma who had acute diplopia with dizziness. The fact that the final diagnosis was ischemic stroke in this case after transferred to Emergency Room immediately suggests that diplopia may be a manifestation of emergency neurology. The second case was a 48-year old male with headache and exacerbate diplopia. We demonstrated here a complete diagnostic process for diplopia evaluation in this case. Virus infection of cranial nerve VI was suspected. High-dose corticosteroid was used, but in vain, then modified Ma-Huang-Tang traditional decoction was applied to cure diplopia due to precise pattern identification. By organizing literature information and clinical case analysis, we hope this article can help clinicians with diagnosis, referral and treatment.

Diplopia is a possible clinical presentation of some severe ophthalmologic or neurologic diseases. Clinicians should have enough knowledge and awareness to make differential diagnosis as soon as possible when approaching a patient with diplopia. We organized the information about diplopia from Chinese and Western medicine literature to clarify the thinking process of making differential diagnosis and the principles of Traditional Chinese Medicine’s (TCM) pattern identification and treatment. We used two different cases with diplopia to present the differential diagnosis and treatment processes by pattern identification. The first case was a 67-year old male with hepatocellular carcinoma who had acute diplopia with dizziness. The fact that the final diagnosis was ischemic stroke in this case after transferred to Emergency Room immediately suggests that diplopia may be a manifestation of emergency neurology. The second case was a 48-year old male with headache and exacerbate diplopia. We demonstrated here a complete diagnostic process for diplopia evaluation in this case. Virus infection of cranial nerve VI was suspected. High-dose corticosteroid was used, but in vain, then modified Ma-Huang-Tang traditional decoction was applied to cure diplopia due to precise pattern identification. By organizing literature information and clinical case analysis, we hope this article can help clinicians with diagnosis, referral and treatment.