Rhomboencephalitis due to cocaine-induced bony erosion of skull base.

A 49-year-old man with 10 years of intranasal cocaine use presented with dysphagia. Neurologic examination demonstrated bilateral sixth nerve palsies. Brain MRI showed erosion of the sphenoid sinus walls and a defect in the skull base; the resulting path between the nasal cavity and brainstem permitted rhomboencephalitis and clival osteomyelitis (figure 1). Clival cultures grew methicillin-resistant Staphylococcus aureus. IV antibiotics were administered and switched to oral after 6 weeks. Repeat MRI showed decreased T2 fluid-attenuated inversion recovery brainstem hyperintensity (figure 2). Antibiotics will be used for at least 1 year; surgical reconstruction of the skull base will depend on his abstinence from cocaine.