Teaching NeuroImages: Optic and third cranial nerves infiltration as initial relapse of acute lymphoblastic leukemia

A 34-year-old man with a history of acute lymphoblastic leukemia (ALL) under consolidation treatment presented right-side blurred vision and headache associated with complete third right cranial nerve palsy. Brain MRI (figure, A–E) revealed thickening of the right optic and third nerves. Fundus examination (figure, F) found Roth spots, which are highly suggestive of retinal leukemic infiltration.1 Lumbar puncture revealed blast cells. Other possible differentials were excluded. The right-side headache was probably due to ischemic changes of the nerves secondary to the leukemic infiltration.