Purpose

Horner Syndrome is defined and classified by the disruption of sympathetic innervation from the hypothalamus to the eye through the classic miosis, ptosis and apparent enophthalmos. Medications can be a rare cause of Horner Syndrome and this case report describes a rare and atypical cause of Horner Syndrome thought to be associated with Adalimumab.

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Methods

A 44-year-old female presented to ophthalmology clinic with an 8-month history of a left left upper lid ptosis, and a 2-month history of left pupillary miosis . There was no history of trauma, change in vision, cough, haemoptysis, head/neck pain, or neck masses/lymphadenopathy.. She had a medical history of psoriasis and was a smoker of 20 cigarettes a day. Examination revealed left frontalis overactivity (elevated brow), a 1-2mm left sided ptosis and 2mm anisocoria, with the left pupil being smaller, a visual acuity of 6/4 in both eyes. Intraocular pressures and retinal examination were normal.

Apraclonidine testing demonstrated reversal of anisocoria, supporting a diagnosis of left Horner syndrome. Subsequent cocaine testing showed failure of dilation of the left pupil, further supporting sympathetic denervation.
MRI Head/Neck & Chest X-Ray were unremarkable. Anti-Nuclear Antibody (ANA) Screen was positive (1:1280 titre). Anti-DsDNA IgG antibodies elevated (21.9 IU/mL).

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Results

A joint decision to stop adalimumab and switch to Apremilast was made.

Cessation of adalimumab resulted in a self-reported almost complete resolution of anisocoria. The partial resolution following withdrawal of adalimumab raises the possibility of a reversible immune-mediated autonomic neuropathy, potentially affecting the postganglionic sympathetic pathway. However, pharmacological localization was not performed.

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Conclusion

This rare case presents a possible iatrogenic cause of Horner Syndrome, with a link to Adalimumab therapy. The clinical course is most suggestive of a reversible peripheral/postganglionic sympathetic dysfunction.

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Additional Authors

First name	Last name	Base Hospital / Institution
Ebube	Obi	Royal Gwent Hospital
Andrew	Want	Cardiff University
Andrew	Feyi-Waboso	Royal Gwent Hospital

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