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42 y/o M with Blurred vision for 1+ week

EBM Case discussion. 42 y/o M with Blurred vision for 1+ week. R4 陳怡杏 May 12 th , 2011. Ocular history. Eye hit by silicone last week os, blurred vision now, eye pain c movement for 1wk, than blurred vision+ (ou) recent common cold-, but throat pain+

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42 y/o M with Blurred vision for 1+ week

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  1. EBM Case discussion 42 y/o M with Blurred vision for 1+ week R4 陳怡杏 May 12th, 2011

  2. Ocular history • Eye hit by silicone last week os, blurred vision now, eye pain c movement for 1wk, than blurred vision+ (ou) • recent common cold-, but throat pain+ • past history: denied DM, HTN, CAD • personal history: denied alcohol, smoke, drug abuse history • 2+ year-foreign worker from Tailand

  3. Ocular Examination • 2011/05/02 PT OD:9mmHg OS:12mmHg • TVRM(sD) OD:+0.25/-0.75X83 OS:+4.0/-0.50X45 • VAcC(sD) OD:0.05(0.06X0/-0.75.X80) OS:CF>1M • P: ortho • pupil: isocoric, MG(-) • EOM: f & f • Conj: mild congestion, K: clear, AC : D/Cell+, Lens: clear • color od 5/7 os 0/7

  4. Fundus examination

  5. Fundus examination

  6. OCT 356 612

  7. Tracing back his history… • BP: 120/90mmhg • arthritis (-), oral ulcer (-) • Raised cat in Tailand (+), no cat scratch history

  8. Papilledema+ macular star+seroud rd Diagnosis?

  9. Bilneuroretinitis d/d • Cat scratch disease cat contact history? • Syphillis VDRL, TPHA • Harada’s disease • Sarcoidosis ACE, CXR • Toxoplasmosis Toxo IgG, IgM • Idiopathic neuroretinitis • Lyme disease • Hypertensive retinopathy

  10. CXR • Normal heart size • Tortuosity of thoracic aorta • Infiltration at bil. lower lungs

  11. LAB

  12. post Cortrimazole 1wk

  13. oct

  14. FAG+ICG

  15. FAG+ICG

  16. FAG+ICG

  17. FAG+ICG

  18. FAG+ICG

  19. FAG+ICG

  20. Neuroretinitis • First described by Leber in 1916 • characterized by (1) sudden onset of VA loss (2) partial or complete macula star exudate (preceded by a peripapillary exudative neurosensory RD), and (3) optic nerve swelling with disc capillary leakage • Usually unilateral • Cause: cat scratch disease 2/3

  21. Neuroretinitis-presentation • Gass: FAG-retinal leakage (-) and optic nerve swelling preceded or occurred in conjunction with the formation of a macular star • Pathophysiology: optic neuropathy with prelaminar permeability of disc capillaries producing the apparent retinal thickening and secondary macular exudates

  22. Macular exudation • Usually disc edema first • Macular exudation often manifests within 2-4 wks after disease onset • Often emerges as disc edema resolving (7 to 10 day from its initial appearance) • May remain stable for several wks but gradually resolve within 6 to 12 m/o • Disc edema: begins to decrease in 2 weeks and usually complete resolution in 8 to 12 wks

  23. Neuroretinitis-pathogen

  24. recurrent neuroretinitis • In the same/fellow/both eyes • Accumulative visual loss after each episode • Incomplete recovery of visual function: due to permanent damage to the optic nerve, not the macula • Pathogenesis: patients without systemic disease may have immune disorder involving disc vasculature Ach Ophthalmol. 2003; 121: 65-67 J Neuro-Ophthalmol 2005;25: 286–288

  25. recurrent neuroretinitis • 30 pt with recurrent NR, 7 pts had immunosuppresants (prednisone, azathioprine, or both) • Attack rate decreased 72% after initiation of immunosuppressive therapy (0.58-> 0.16 attacks/yr) • Other disease association: Toxoplasmosis, melanocytoma, sarcoidosis, multiple sclerosis

  26. Cat scratch disease-presentation • Most common :lymphadenitis • Atypical forms: Parinaud oculoglandular syndrome, stellate neuroretinitis (10%), persistent fever without localizing signs, hepatosplenic infection, encephalopathy, osteomyelitis, and endocarditis

  27. Cat-scratch disease • First described by Parinaud in 1889

  28. Hiv in csd • seroprevalence of Bartonella in patients with HIV infection: 16% to 40%, but seropositivity does not correlate directly with evidence of clinical infection

  29. CSD-diagnosis • LN biopsy or conjunctiva biopsy • Indirect fluorescent antibody (IFA) test: 88% sensative, 94% specific • Enzyme immunoassay (EIA) IgG sensitivity 86-95%, specificity 96% compare to IFA • PCR: amplify small fragment of bacterial 16S rRNA gene of Bartonella DNA

  30. Treatment of csd • Efficacy: Rifampin (87%), Ciprofloxacin (84%), gentamicin (73%) trimethoprim and sulfamethoxazole (58%) • Penicillins, cephalosporins, tetracycline, and erythromycin had minimal or no clinical efficacy • Immocompetants: rapidly responsive to many antibacterial agents, including those not felt to be effective • Immunocompromised pts: gentamicin, macrolides, quinolones, and rifampin Current Opinion in Pediatrics 2001, 13:56–59

  31. Cat-scratch disease has been confirmed as a cause of optic neuritis as well as neuroretinitis Optic neuritis/papillitis in csd

  32. 49 y/o M, 21142522 • CC: progressive blurred vision od for 3 months • 2011/03/01 VA OD:0.1+1 OS:L-S(-), RAPD (os)3+ • PH: • optic neuritis (od) s/p steroid pulse therapy 1/20-1/23 2008 (2008/10/6 VA od 0.4) • optic neuritis(os) s/p steroid pulse therapy at NTUH with optic atrophy

  33. Fundus exam

  34. CT (-) • CXR np • LAB survey: WNL

  35. Pre-tx (2011/3) • Post- tx • 3 day pulse therapy • +doxycycline • (2011/4/28)

  36. #20010799 41 y/o M, metamorphopsia (OD) since July 2010, grey color and then black Rnfl thinning after neuroretinitis

  37. 2010/7 2010/9 Since 2010/11

  38. 2010/11 2011/4

  39. Oct initial-final 2010/7 2011/4

  40. Thank you for your listening~

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