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.