Sixteen syndrome: a new pontine opthalmo-neurological syndrome within the one and a half syndrome spectrum of disorders in a diabetic patient- a case report

Abstract

A 52-year-old diabetic, male presented with dizziness, diplopia, salivation, and mild weakness in the right limb for 3 days. Neurological examination revealed complete inaccessibility of adduction of the left eye and incomplete mild abduction. The bilateral frontal lines were shallow, the eyes could not close completely, the mouth angle was drooping, also the patient had difficulty of blowing the cheeks with hydrostomia salivation. The right upper and lower limbs were mildly weak and the right side was positive for Babisnki reflex. Laboratory tests showed an increase in fasting blood glucose (10.02 mmol/L) and glycated hemoglobin (8.1%). Urine routine glucose (4+), low-density lipoprotein cholesterol (2.49 mmol/L), and homocysteine ??levels were normal. Magnetic resonance diffusion-weighted imaging and apparent diffusion coefficient showed bilateral pontine tegmentum and pars basilaris intrusion. He was given dual antiplatelet therapy, statin therapy, antihypertensive and antidiabetic therapy. After 2 days, the right limb weakness was completely restored, but positive Babinski reflex continued. He was discharged after 10 days with significant improvement in dizziness. After one month of follow-up, diplopia disappeared leaving only a slight peripheral facial paralysis on the left side. This kind of case is extremely rare and it further expands the landscape of ponto-opthalmic disorders. Knowledge of the clinical features will help in identifying the lesion locus which may improve the clinical practice and standard of care in diabetic patients.