A 21-year-old Caucasian female presented to the Wills Retina Service with a three-day history of bilateral decreased vision, worse in the right eye. She denied any flashes, floaters, or associated complaints. Three weeks prior she had an episode of sinusitis treated with amoxicillin for 10 days as an outpatient. One week prior she developed high fevers to 103 F, severe headache, retrobulbar ache, neck pain and stiffness, nausea and vomiting, confusion, diffuse myalgias and a bilateral lower extremity nontender papular erythematous rash. At a community emergency department she was rehydrated, given Benadryl, and a lumbar puncture was performed, which ruled out bacterial meningitis. She was discharged on azithromycin and her systemic symptoms and fever resolved prior to her presentation to the Wills Retina service.
Past ocular history was unremarkable and past medical history was significant for migraine headache and Lyme disease, which was previously treated. Immunizations were up to date. Her only medication was an oral contraceptive. Family history was notable for a maternal grandmother with multiple sclerosis. She denied any sick contacts, recent travel and bug or animal bites. She has two indoor dogs and cats and two indoor cats and works at a veterinary clinic. She lives in a university dormitory. She denied any history of sexually transmitted infections, or alcohol or IV drug use.
Figure 1. Fundus photos revealing: A) optic disc edema, macular edema, severe diffuse periphlebitis and white-centered retinal hemorrhages OD; B) less-severe optic disc edema, periphlebitis and white-centered retinal hemorrhages OS. |
Uncorrected visual acuity was count fingers and 20/30 in the right and left eye, respectively, without improvement on pinhole. The right pupil was sluggish, with an afferent pupillary defect, and the left was briskly reactive. Motility was full and intraocular pressure was within normal limits in both eyes. Confrontation visual fields were limited by visual acuity on the right, but full in the left eye. Slit-lamp exam was notable for fine, nongranulomatous, keratic precipitates bilaterally, 1+ anterior cell and flare in the right eye, and trace cell and flare in the left eye. Posterior exam revealed 1+ anterior vitreous cell and macular edema in the right eye, and optic disc edema in both eyes. A diffuse periphlebitis was present bilaterally but worse on the right, and multiple, white-centered retinal hemorrhages were seen in the periphery bilaterally (See Figure 1)
. Neurologic exam was unremarkable.
What is your differential diagnosis? What further workup would you pursue?
Please click this link for diagnosis, workup, treatment and discussion.