Discussion and conclusions
Meeting the following four diagnostic criteria is used as definition of
Garcin syndrome: 1. unilateral palsies of the cranial nerves, 2. neither
sensory nor motor long-tract disturbance, 3. no intracranial
hypertension, and 4. an osteoblastic lesion in the skull base(10). Most
cases with Garcin syndrome are susceptible to primary or secondary bone
tumors and a few exhibits inflammatory disorders. In the majority of
cases not all twelve brain nerves are affected(11).
Based on reports, there have been various causes for Garcin Syndrome
including tonsillar carcinoma, mucinous adenocarcinoma of the
nasopharynx(12), nasopharyngeal carcinoma(13), adenoid cystic
carcinoma(14), parotid gland adenoid cystic carcinoma(15) , and
rhinocerebral mucormycosis (in an aged with diabetic man)(16, 17), skull
base metastasis of ACDK-related RCC (which is a known unique carcinoma
that occurs in patients with long-term HD)(18). The slow localized
growth of these tumors is determination of the Garcin syndrome, rather
than by their histology and primary localization(12). There are also
Collet-Sicard syndrome, cavernous sinus syndrome, Tolosa-Hunt syndrome
which represent similar clinical findings with Garcin syndrome. These
syndromes occur due to paralysis of a certain cranial nerve (e.g.,
Collet-Sicard is IX to XII)(7). For timely diagnosis of Garcin syndrome,
findings on computed and magnetic resonance tomography play crucial
role(12). According to some reports, performing biopsy in cases with
Garcin syndrome also provides beneficial information(19).
The symptomatic duration of Garcin syndrome among patients varies from
two months to seven years(20). The prognosis is as a rule unfavorable.
Garcin syndrome usually is a late presentation of disorders. The skull
basillar meninges and bones are the most common places that involved.
Direct extension and invasion by nasopharyngeal carcinoma or primary
tumor of the skull base are the main cause of basal meningitis. The
clinical presentation is usually as progressive cranial nerve palsies.
The pathological process of direct extension of tumors may affect the
cranial nerves at their exit sites from the skull or in their
extracranial pathways (21).
Tumors of the parapharyngeal space (PPS), a potential space lateral to
the upper pharynx, occur less than 1% of all head and neck
malignancies. (3, 8, 9). Among lymphoprolifrative neoplasms, diffuse
large B-cell lymphoma declare as the most common type in the United
States (22).
Diagnostic work-up for HIV infection is mandatory for patients with risk
factors, especially those with large cell or small noncleaved-cell
histopathologies(23). Fluorodeoxyglucose (FDG) positron emission
tomography with computed tomography (PET/CT) is the preferred imaging
modality for staging FDG-avid nodal lymphomas, while CT alone is
preferred for FDG-non-avid and variably FDG-avid histopathology(8).
This patient had AIDS as a risk factor and his presentation was
misleading abdominal, parapharyngeal, nervous signs, and symptoms. He
needed an imaging study to find the cause of presentations and also
surgery and histopathological study.
Lymphoma is one of the differential diagnoses for a patient presenting
with PPS mass and Garcin syndrome. In our patient, cervical mass and
several masses in the lung and spleen were seen. Lymphoma is one of the
most important differential diagnosis that we should think about it in
the same patients. Lymphoma can involve various organs like lung,
spleen, and parapharyngeal space. It is important that to take medical
decisions fast and also medical invasive diagnostic and therapeutic
workup perform as soon as possible.