Sir,

We report a case of bilateral Adie's pupil with bilateral facial nerve palsy, following acute pancreatitis, which has not been previously reported.

Case report

A 41-year-old in-patient with gallstone pancreatitis was referred to ophthalmology with blurred vision and red eyes. On examination he had bilateral acute anterior uveitis. He was started on G.dexamethasone 0.1% and G.cyclopentolate 1% for both eyes. Overnight he developed bilateral facial nerve palsies, and was further investigated for sarcoid by MRI, lumbar puncture, CXR and CT thorax, and serum/CSF ACE. These results were negative, as were investigations for Lyme disease and syphilis. The patient was later discharged, but was readmitted with a recurrence of pancreatitis. On review his facial nerve palsies had improved. VA was 6/5 bilaterally; pupils were dilated with no reaction to light but a slow accommodation response. After 4 weeks, the patient's facial nerve palsies had completely resolved. VA was 6/6 bilaterally, his right pupil was 6.5 mm and unresponsive to light. His left pupil was 6.2 mm with a sluggish light response and segmental vermiform iris movement. Pilocarpine 0.125% was instilled into both eyes and the pupils rechecked after 25 min. Both pupils had constricted significantly, and the patient reported an improvement in near vision. In the absence of other pathology, a diagnosis of bilateral Adie's pupil was made.

Comment

Reported causes of Adie's pupil include infection,1 inflammation,2 ischaemia, anaesthesia, toxicity, neuropathy,3 tumours,4 and trauma.5 In this case the bilateral Adie's pupil developed with bilateral facial nerve palsies. Such palsies may be a result of sarcoidosis, Guillain-Barré syndrome, Lyme disease, syphilis, Epstein–Barr infection, malignancy, or leprosy. The most likely link between pancreatitis, bilateral facial nerve palsies and Adie's pupil is sarcoidosis, although in this case tests were negative. A less likely possibility is Guillain-Barré of the cranial nerves (polyneuritis cranialis6), although CSF protein was normal and the patient denied autonomic symptoms. A third possibility is syphilis7 but again, investigations were normal.

No direct link has been reported between a facial nerve palsy and Adie's pupil. There are, however, a number of viruses known to cause one or the other. We postulate that there could be an underlying viral aetiology linking all three conditions. Although, at first glance, the pancreatitis seems to be due to gallstones, it may be exacerbated by infection with an enterovirus, mumps virus, cytomegalovirus or herpes simplex virus. Enteroviruses, particularly, are well known for their manifestations in the alimentary canal and the central nervous system.

In this case the patient was not investigated for a viral infection, but it highlights the need to consider viral causes for unusual presentations of common problems.