Senior Report 8.24

seniorreport

Case Presentation by Eugene Rozen, MD

Case 1

25 year old female with headache, fever, malaise, rash, left sided eye pain. Symptoms have been worsening over the 2 days. She has a history of congenital HIV, she has not seen her doctor in over 1 year and takes no medication.

Right Eye Left Eye
Conjunctiva Normal Red
Photophobia None Positive
Pupils 4mm, brisk 4mm, brisk
Acuity 20/30 20/70
Pressure 15 15
Fluorescein Normal Normal
Fundus Normal Normal

8.242

1. What treatment should be started?

A. Acyclovir IV

B. Clindamycin IV

C. Dexamethasone (High Dose) IV

D. Gatifloxacin Eye Drops

E. HAART

Case 2

53 year old male with history of AIDS presents complaining of blurry vision. He has been on multiple HAART regimens. His last CD4 count, 4 months ago, was 48 with a high viral load.

Right Eye Left Eye
Conjunctiva Normal Normal
Photophobia None None
Pupils 5mm, relative afferent pupillary defect 5mm, brisk
Acuity 20/200 20/50
Pressure 14 14
Fluorescein Normal Normal
Fundus See below See below

8.24

2. Pathology of what structure does the relative afferent pupillary defect signify?

A. Ciliary Body

B. Choroid plexus

C. Cornea

D. Optic Nerve

E. Retina

Case 3

52 year old male complaining of “seeing double”. Symptoms reported as worsening over the last 3 months. No other symptoms except occasional headache over the same period. Patient has a history of AIDS. No diplopia is reported when each eye is tested individually.

Right Eye Left Eye
Conjunctiva Normal Normal
Photophobia None None
Pupils 3mm, reactive 3mm, reactive
Acuity 20/40 20/20
Pressure 21 14
Fluorescein Normal Normal
Fundus Slight papilledema Normal

8.241

3. What study should be ordered next?

A. CT head, non-contrast

B. CT head/orbits with contrast

C. ESR and CRP

D. Lumbar puncture

E. TSH/T4

 

Answers:

1. A

2. D

3. A or B

 

Discussion:

Case 1: A
The patient in this case has herpes zoster ophthalmicus (HZO). Herpes zoster, or shingles, is reactivation of varicella zoster virus that follows dermatomes. In the case of HZO the affected dermatome is the ophthalmic branch of the trigeminal nerve (V1). The vesicle on the tip of her nose is referred to as Hutchinson’s sign.

The patient’s ocular manifestation in this case resembles conjunctivitis (red eye) and iridocyclitis (photophobia), but HZO can affect any number of structures including the sclera, retina, optic nerve, lids, and extraocular muscles.

The treatment for herpes zoster varies depending on the timing of symptoms and the severity of disease. Generally, treatment is supportive.

Acyclovir and other antivirals (choice A) are effective in shortening the duration of symptoms, preventing the occurence of further symptoms, treating complications and preventing post-herpetic neuralgia. In immunocompromised patients, IV acyclovir is the drug of choice. For more simple cases, a 7-21 day course of antivirals can be beneficial, especially in instituted in the preeruptive phase or within 72 hours of vesicle formation. Antibiotics, especially IV ones (choice B), have no indication in this case, although topical antibiotics (choice D) could be helpful in preventing superinfection.
Steroids (choice C) have been used in treating zoster. They have a potential to help with pain, decrease progression to post herpetic neuralgia and diminish severity of symptoms. Their use hasn’t been borne out in clinical trials and they would not be the treatment of choice in this case.

Case 2: D
This patient has CMV retinitis. Inspection of the fundus reveals retinal inflammation in a pattern consistent with CMV retinitis called a “cheese pizza” appearance. On examination of the fundus, some faint papilledema and blurred margins are visible, consistent with damage to the optic nerve (choice D).
A relative afferent pupillary defect (RAPD), or Marcus-Gunn pupil is a finding elicited with a ‘swinging flashlight test’. It’s much easier to explain with this link: https://www.youtube.com/watchv=HSYo7LhfV3A

 

8.243

Case 3: A or B
This question was poorly worded.
This patient has a constellation of symptoms that point to an orbital mass lesion, and the main item on the differential should be an ocular tumor. HIV/AIDS is a risk factor for CNS lymphoma and ocular lymphoma can be a manifestation of it. The ocular component can either be primary or a site of metastasis.
The workup of suspected intracranial/CNS pathology in the ED typically starts with a non-contrast CT scan of the head (choice A), however, in this case, there is good reason to consider ordering the CT with contrast initially to evaluate for a tumor.
The patient has diplopia as a result of proptosis (which is why is it binocular diplopia). He has an elevated intraocular pressure, papilledema and a prolonged course of symptoms. This should strongly point to the presence of an ocular mass.

 

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