A Rare Case of Plus Minus Syndrome

Bharat Rajkumar; Ajay Nathan; Abish Mohan; Cherukara Nihil

doi:doi:10.11648/j.ijmcr.20250401.14

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A Rare Case of Plus Minus Syndrome

Bharat Rajkumar, Ajay Nathan, Abish Mohan, Cherukara Nihil^*

Published in International Journal of Medical Case Reports (Volume 4, Issue 1)

Received: 12 February 2025 Accepted: 10 March 2025 Published: 21 March 2025

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Abstract

Plus-minus syndrome is a rare neurological disorder marked by asymmetric eyelid dysfunction, typically linked to midbrain lesions. We present a case of a 32-year-old male who developed right-sided partial ptosis and left eyelid retraction following a febrile illness. Apart from these ocular findings, his neurological examination was unremarkable. Extensive investigations, including MRI brain, CE MRI brain, MRA, cerebrospinal fluid analysis, and nerve conduction studies, revealed no abnormalities. Given the recent infection and absence of structural lesions, a post-infectious demyelinating process was suspected. The patient was treated with a brief course of oral steroids, resulting in complete symptom resolution within four days. This case highlights a unique presentation of plus-minus syndrome without radiological evidence of midbrain involvement, suggesting an inflammatory or immune-mediated mechanism. It underscores the importance of considering non-structural causes in similar cases and supports the potential benefit of early corticosteroid therapy.

Published in	International Journal of Medical Case Reports (Volume 4, Issue 1)
DOI	10.11648/j.ijmcr.20250401.14
Page(s)	21-25
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2025. Published by Science Publishing Group

Keywords

Plus-minus Syndrome, Unilateral Ptosis, Ocular Myasthenia, Ocular Myositis

References

[1]	Cahill KE, Biousse V. "Plus-minus lid syndrome: clinical and radiological features." J Neuroophthalmol. 2008; 28(1): 35-39.
[2]	Brazis PW, Lee AG. "Midbrain syndromes: Diagnosis and clinical implications." Neurology. 2011; 77(15): 1333-1340.
[3]	Fisher CM. "Ocular motor signs in midbrain and pontine infarctions." Arch Neurol. 2000; 57(10): 1273-1280.
[4]	Leigh RJ, Zee DS. The Neurology of Eye Movements. 5th ed. Oxford University Press; 2015.
[5]	Nakamura Y, Hasegawa Y. "Oculomotor nerve palsy associated with midbrain infarction." Intern Med. 2013; 52(23): 2669-2672.
[6]	Scherer R, Bisdorff AR. "Pseudo plus-minus lid syndrome in myasthenia gravis." Eur J Neurol. 2015; 22(3): e31-e32.
[7]	Mehta A, Robertson CE. "Post-infectious neurological syndromes: pathophysiology and treatment considerations." Curr Neurol Neurosci Rep. 2022; 22(5): 151-162.
[8]	Sheetal S, Thomas R, Kumar A S, Tomy L G. Plus-minus lid syndrome with ataxia and severe apathy—A rare manifestation of midbrain infarct. J Postgrad Med 2020; 66: 162-4.
[9]	Gaymard B, Lafitte C, Gelot A, de Toffol B. Plus-minus lid syndrome. J Neurol Neurosurg Psychiatry. 1992; 55: 846-848.
[10]	Kotwal V, Shenoy W, Joshi S, et al. Plus minus lid syndrome with ataxia. J Assoc Physicians India. 2005; 53: 908-909.
[11]	Alsherbini K, Kapadia K, Sattin J. A rare midbrain infarction presenting with plus minus lid syndrome with ataxia: A case report. Journal of Medical Case Reports. 2011; 5: 525.
[12]	Bandini, Fabio. (2009). Pseudo Plus-Minus Lid Syndrome. Archives of neurology. 66. 668-9. https://doi.org/10.1001/archneurol.2009.37
[13]	Gandhi RA, Nair AG. Ocular myasthenia gravis. In: Chaudhari Z, Vanathi M, editors. Postgraduate Ophthalmology. New Delhi: Jaypee Brothers Medical Publishers; 2011. pp. 1510–21.
[14]	Barkhof, Frederik the clinico-radiological paradox in multiple sclerosis revisited, Current Opinion in Neurology: June 2002 - Volume 15 - Issue 3 - p 239-245.

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APA Style

Rajkumar, B., Nathan, A., Mohan, A., Nihil, C. (2025). A Rare Case of Plus Minus Syndrome. International Journal of Medical Case Reports, 4(1), 21-25. https://doi.org/10.11648/j.ijmcr.20250401.14

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ACS Style

Rajkumar, B.; Nathan, A.; Mohan, A.; Nihil, C. A Rare Case of Plus Minus Syndrome. Int. J. Med. Case Rep. 2025, 4(1), 21-25. doi: 10.11648/j.ijmcr.20250401.14

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AMA Style

Rajkumar B, Nathan A, Mohan A, Nihil C. A Rare Case of Plus Minus Syndrome. Int J Med Case Rep. 2025;4(1):21-25. doi: 10.11648/j.ijmcr.20250401.14

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@article{10.11648/j.ijmcr.20250401.14,
  author = {Bharat Rajkumar and Ajay Nathan and Abish Mohan and Cherukara Nihil},
  title = {A Rare Case of Plus Minus Syndrome
},
  journal = {International Journal of Medical Case Reports},
  volume = {4},
  number = {1},
  pages = {21-25},
  doi = {10.11648/j.ijmcr.20250401.14},
  url = {https://doi.org/10.11648/j.ijmcr.20250401.14},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ijmcr.20250401.14},
  abstract = {Plus-minus syndrome is a rare neurological disorder marked by asymmetric eyelid dysfunction, typically linked to midbrain lesions. We present a case of a 32-year-old male who developed right-sided partial ptosis and left eyelid retraction following a febrile illness. Apart from these ocular findings, his neurological examination was unremarkable. Extensive investigations, including MRI brain, CE MRI brain, MRA, cerebrospinal fluid analysis, and nerve conduction studies, revealed no abnormalities. Given the recent infection and absence of structural lesions, a post-infectious demyelinating process was suspected. The patient was treated with a brief course of oral steroids, resulting in complete symptom resolution within four days. This case highlights a unique presentation of plus-minus syndrome without radiological evidence of midbrain involvement, suggesting an inflammatory or immune-mediated mechanism. It underscores the importance of considering non-structural causes in similar cases and supports the potential benefit of early corticosteroid therapy.
},
 year = {2025}
}

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TY  - JOUR
T1  - A Rare Case of Plus Minus Syndrome

AU  - Bharat Rajkumar
AU  - Ajay Nathan
AU  - Abish Mohan
AU  - Cherukara Nihil
Y1  - 2025/03/21
PY  - 2025
N1  - https://doi.org/10.11648/j.ijmcr.20250401.14
DO  - 10.11648/j.ijmcr.20250401.14
T2  - International Journal of Medical Case Reports
JF  - International Journal of Medical Case Reports
JO  - International Journal of Medical Case Reports
SP  - 21
EP  - 25
PB  - Science Publishing Group
SN  - 2994-7049
UR  - https://doi.org/10.11648/j.ijmcr.20250401.14
AB  - Plus-minus syndrome is a rare neurological disorder marked by asymmetric eyelid dysfunction, typically linked to midbrain lesions. We present a case of a 32-year-old male who developed right-sided partial ptosis and left eyelid retraction following a febrile illness. Apart from these ocular findings, his neurological examination was unremarkable. Extensive investigations, including MRI brain, CE MRI brain, MRA, cerebrospinal fluid analysis, and nerve conduction studies, revealed no abnormalities. Given the recent infection and absence of structural lesions, a post-infectious demyelinating process was suspected. The patient was treated with a brief course of oral steroids, resulting in complete symptom resolution within four days. This case highlights a unique presentation of plus-minus syndrome without radiological evidence of midbrain involvement, suggesting an inflammatory or immune-mediated mechanism. It underscores the importance of considering non-structural causes in similar cases and supports the potential benefit of early corticosteroid therapy.

VL  - 4
IS  - 1
ER  -

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Author Information

Bharat Rajkumar

Department of Medicine, INHS Sanjivani Hospital, Kochi, India

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Ajay Nathan

Department of Medicine, INHS Sanjivani Hospital, Kochi, India

Contact Email
Abish Mohan

Department of Medicine, INHS Sanjivani Hospital, Kochi, India

Contact Email
Cherukara Nihil

Coast Guard District Headquarters No.4, Indian Coast Guard, Kochi, India

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Plain Text BibTeX RIS

APA Style

Rajkumar, B., Nathan, A., Mohan, A., Nihil, C. (2025). A Rare Case of Plus Minus Syndrome. International Journal of Medical Case Reports, 4(1), 21-25. https://doi.org/10.11648/j.ijmcr.20250401.14

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ACS Style

Rajkumar, B.; Nathan, A.; Mohan, A.; Nihil, C. A Rare Case of Plus Minus Syndrome. Int. J. Med. Case Rep. 2025, 4(1), 21-25. doi: 10.11648/j.ijmcr.20250401.14

Copy | Download

AMA Style

Rajkumar B, Nathan A, Mohan A, Nihil C. A Rare Case of Plus Minus Syndrome. Int J Med Case Rep. 2025;4(1):21-25. doi: 10.11648/j.ijmcr.20250401.14

Copy | Download

@article{10.11648/j.ijmcr.20250401.14,
  author = {Bharat Rajkumar and Ajay Nathan and Abish Mohan and Cherukara Nihil},
  title = {A Rare Case of Plus Minus Syndrome
},
  journal = {International Journal of Medical Case Reports},
  volume = {4},
  number = {1},
  pages = {21-25},
  doi = {10.11648/j.ijmcr.20250401.14},
  url = {https://doi.org/10.11648/j.ijmcr.20250401.14},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ijmcr.20250401.14},
  abstract = {Plus-minus syndrome is a rare neurological disorder marked by asymmetric eyelid dysfunction, typically linked to midbrain lesions. We present a case of a 32-year-old male who developed right-sided partial ptosis and left eyelid retraction following a febrile illness. Apart from these ocular findings, his neurological examination was unremarkable. Extensive investigations, including MRI brain, CE MRI brain, MRA, cerebrospinal fluid analysis, and nerve conduction studies, revealed no abnormalities. Given the recent infection and absence of structural lesions, a post-infectious demyelinating process was suspected. The patient was treated with a brief course of oral steroids, resulting in complete symptom resolution within four days. This case highlights a unique presentation of plus-minus syndrome without radiological evidence of midbrain involvement, suggesting an inflammatory or immune-mediated mechanism. It underscores the importance of considering non-structural causes in similar cases and supports the potential benefit of early corticosteroid therapy.
},
 year = {2025}
}

Copy | Download

TY  - JOUR
T1  - A Rare Case of Plus Minus Syndrome

AU  - Bharat Rajkumar
AU  - Ajay Nathan
AU  - Abish Mohan
AU  - Cherukara Nihil
Y1  - 2025/03/21
PY  - 2025
N1  - https://doi.org/10.11648/j.ijmcr.20250401.14
DO  - 10.11648/j.ijmcr.20250401.14
T2  - International Journal of Medical Case Reports
JF  - International Journal of Medical Case Reports
JO  - International Journal of Medical Case Reports
SP  - 21
EP  - 25
PB  - Science Publishing Group
SN  - 2994-7049
UR  - https://doi.org/10.11648/j.ijmcr.20250401.14
AB  - Plus-minus syndrome is a rare neurological disorder marked by asymmetric eyelid dysfunction, typically linked to midbrain lesions. We present a case of a 32-year-old male who developed right-sided partial ptosis and left eyelid retraction following a febrile illness. Apart from these ocular findings, his neurological examination was unremarkable. Extensive investigations, including MRI brain, CE MRI brain, MRA, cerebrospinal fluid analysis, and nerve conduction studies, revealed no abnormalities. Given the recent infection and absence of structural lesions, a post-infectious demyelinating process was suspected. The patient was treated with a brief course of oral steroids, resulting in complete symptom resolution within four days. This case highlights a unique presentation of plus-minus syndrome without radiological evidence of midbrain involvement, suggesting an inflammatory or immune-mediated mechanism. It underscores the importance of considering non-structural causes in similar cases and supports the potential benefit of early corticosteroid therapy.

VL  - 4
IS  - 1
ER  -

Copy | Download