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The report describes a previously healthy 37-year-old man with acute meningeal signs and binocular horizontal diplopia. MRI demonstrated a ring-enhancing pontine lesion with diffusion restriction and posterior interruption at the fourth-ventricle interface, consistent with rupture. Empirical intravenous antibiotics led to complete clinical recovery, highlighting imaging for early diagnosis and differentiating infectious from non-infectious pontine lesions.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/clinicoradiologic-correlation-in-bilateral-internuclear-ophthalmoplegia-revealing-a-ruptured-pontine-abscess/458406/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/clinicoradiologic-correlation-in-bilateral-internuclear-ophthalmoplegia-revealing-a-ruptured-pontine-abscess/458406.png","ImageObject",300,407,{"name":92,"@type":93},"นรินทร์","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-01","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":39},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What typically causes internuclear ophthalmoplegia (INO)?","Question",{"text":112,"@type":113},"INO is most often associated with demyelinating disorders or brainstem infarction due to medial longitudinal fasciculus involvement.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What did MRI show in this case?",{"text":117,"@type":113},"MRI revealed a ring-enhancing pontine lesion with diffusion restriction and posterior interruption of enhancement at the interface with the fourth ventricle, consistent with a ruptured pontine abscess.",{"name":119,"@type":110,"acceptedAnswer":120},"How was the diagnosis and infection cause supported despite negative cultures?",{"text":121,"@type":113},"CSF showed marked neutrophilic pleocytosis, high protein, and low glucose, which strongly supported bacterial meningitis even though Gram stain and bacterial cultures were negative and extensive microbiological tests were negative.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},458406,1790793090,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":39,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":24,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":144,"preview_page_count":4},2336475104957,"https://ap-avatar.wpscdn.com/avatar/22000c4c6bd8a5076e1?x-image-process=image/resize,m_fixed,w_180,h_180&k=1787554080175789136","Review began 11/18/2025  \nReview ended 12/03/2025  \nPublished 12/07/2025  \n© Copyright 2025  \nMebrouk et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited.  \nDOI: 10.7759/cureus.98671  \nOpen Access Case Report  \nClinicoradiologic Correlation in Bilateral Internuclear Ophthalmoplegia Revealing a Ruptured Pontine Abscess  \nYassine Mebrouk 1, Fatima Ez-Zahra Mabrouki 2  \n1. Department of Neurology, University Hospital Mohammed VI, Faculty of Medicine and Pharmacy, Mohammed I University, Oujda, MAR 2. Department of Ophthalmology, University Hospital Mohammed VI, Faculty of Medicine and Pharmacy, Mohammed I University, Oujda, MAR  \nCorresponding author: Yassine Mebrouk, [mebrouky@gmail.com](mebrouky@gmail.com)  \nAbstract  \nInternuclear ophthalmoplegia (INO) is an uncommon but well-recognized clinical sign, most frequently associated with demyelinating disorders or brainstem infarction. Its occurrence in the context of an infectious process, particularly a brainstem abscess, is exceptional. We report the case of a previously healthy 37-year-old man who presented with acute meningeal signs and binocular horizontal diplopia. Magnetic resonance imaging (MRI) revealed a ring-enhancing pontine lesion with diffusion restriction and posterior interruption of enhancement at the interface with the fourth ventricle, consistent with a ruptured brainstem abscess. The patient responded favorably to empirical intravenous antibiotic therapy and achieved complete clinical recovery. This case is noteworthy because of the unusual anatomical location of the abscess and its distinctive clinical presentation, underscoring the crucial role of imaging in early diagnosis. It further emphasizes that infectious etiologies should be considered in patients presenting with INO and shows how specific MRI features can help in distinguishing infectious from non-infectious pontine lesions.  \nCategories: Neurology  \nKeywords: brainstem lesion, internuclear ophthalmoplegia, magnetic resonance imaging, pontine abscess, ringenhancing lesion  \nIntroduction  \nRing-enhancing brain lesions on neuroimaging give rise to a broad differential diagnosis, including  \nneoplasms, infections, demyelinating disorders, and vascular insults [1] . Pontine abscesses are rare,  \nparticularly in immunocompetent adults, and their clinical presentation may be atypical, often mimicking  \nother brainstem pathologies [2,3] .  \nInternuclear ophthalmoplegia (INO), which results from a lesion of the medial longitudinal fasciculus (MLF), is traditionally associated with demyelinating diseases such as multiple sclerosis or with brainstem  \ninfarction. Infectious causes of INO remain exceptionally rare [4,5] .  \nThis case is remarkable for the exceptional pontine location of the abscess and its rare presentation with INO. It highlights the diagnostic value of brain magnetic resonance imaging (MRI) in identifying infectious brainstem lesions and underscores the need to consider infectious etiologies when INO appears in an  \natypical clinical context.  \nCase Presentation  \nWe report the case of a previously healthy 37-year-old man with no personal or family history of Behçet 's  \ndisease, autoimmune disorders, neoplasia, or immunosuppression. He developed subacute  \nmeningoencephalitic syndrome beginning with intense diffuse headache resistant to analgesics,  \naccompanied by projectile vomiting. Within a few days, he developed persistent horizontal diplopia, more  \npronounced on lateral gaze. Visual acuity was preserved, and he denied any motor or sensory deficits,  \nseizures, or focal neurological symptoms. On admission, he was febrile at 39°C (≈102 .2°F) and fully  \nconscious. Neurological examination revealed clear signs of meningeal irritation, including neck stiffness and photophobia. Oculomotor e","cbCaiekVgE5KdGo2","https://ap.wps.com/l/cbCaiekVgE5KdGo2","pdf",1787544,"English","# Abstract\n# Introduction\n## Diagnostic context of ring-enhancing brain lesions\n# Case Presentation\n## Clinical presentation and neurologic findings\n## Laboratory and imaging workup\n# How to cite this article","[{\"question\":\"What typically causes internuclear ophthalmoplegia (INO)?\",\"answer\":\"INO is most often associated with demyelinating disorders or brainstem infarction due to medial longitudinal fasciculus involvement.\"},{\"question\":\"What did MRI show in this case?\",\"answer\":\"MRI revealed a ring-enhancing pontine lesion with diffusion restriction and posterior interruption of enhancement at the interface with the fourth ventricle, consistent with a ruptured pontine abscess.\"},{\"question\":\"How was the diagnosis and infection cause supported despite negative cultures?\",\"answer\":\"CSF showed marked neutrophilic pleocytosis, high protein, and low glucose, which strongly supported bacterial meningitis even though Gram stain and bacterial cultures were negative and extensive microbiological tests were negative.\"}]","Clinicoradiologic Correlation in Bilateral Internuclear Ophthalmoplegia Revealing a Ruptured Pontine Abscess | PDF",1790752872,13]