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Unexplained Fever in Pregnancy

Learn about a rare case of SLE retinopathy in a pregnant woman, including diagnosis, treatment, and follow-up care. Detailed information on ocular manifestations and the importance of timely intervention.

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Unexplained Fever in Pregnancy

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  1. Dr.RathinamSivakumar Uveitis Services Consultant, Uveitis Service Aravind Eye Hospital Madurai India Unexplained Fever in Pregnancy

  2. General History • 26 year old lady, engineer • sudden painless loss of vision in BE since 3 days • fever and cough for two months • cough was associated with haemoptysis • amenorrhea of 3 months,hospitalized and treated with ATT at general gynecology department. • Then referred to our hospital

  3. EXAMINATION

  4. Initial Diagnosis of Ocular Disease Retinal vascular occlusive disease of unknown origin

  5. Investigations • Hb: 7g% • WBC: 8,600 cells/cumm, platelets: 2 lakhs/cumm • ESR: 28mm at ½ hr, 55mm at 1 hr • Bleeding & Clotting Time : Normal • CRP: 22.9mg/ lit (N: up to 6 mg/l) • serum amylase: 91 IU/L (0 to 85 IU/L) • serum rheumatoid factor: 3.14 IU/ml (0 to 30) • plasma fibrinogen: 182 mg% • BL.glucose; sr creatinine; blood urea: WNL • PS: MICROCYTIC HYPOCHROMIC ANEMIA; • NEGATIVE FOR MALARIAL PARASITE • urine analysis: trace albumin

  6. Differential Diagnosis • Adamantiades – Behcet´s Disease • Polyarteriitisnodosa • Takayasu disease • Wegeners granulomatosis • syphilis • systemic lupus erythematosus

  7. History Review • h/o hair loss • h/o malar rash • occasional joint pains • no h/o oral or genital ulcers • no h/o headache • no h/o DM or HTN in self or family

  8. Diagnosis SLE Retinopathy

  9. Immediate Treatment • intravitreal triamcinolone acetate 0.1ml was given in BE as a first possible ocular treatment • as the patient was pregnant, she was referred to the Rheumatologist for systemic treatment

  10. Investigation • Rheumatologist for further invest.: • ANA: 9.2mg% (0.9 to 1.4mg%) • Anti Ds DNA; C3, C4; positive • Renal Function Test : WNL • Liver Function Test : WNL

  11. Therapy • all drugs have to be safe in pregnancy • prednisolone 40 mg • ecosprin 75mg • calcium supplement • blood transfusion 1 pint • Counseled for medical termination of pregnancy.

  12. medical termination of pregnancy was carried out. IV cyclophosphamide first cycle pulse methylprednisolone 1gm 3 days and maintained of oral prednisolone 1mg/kg body wt. Therapy – Follow-up

  13. Follow up – After 1 Week Persistent vasculitis and progressive cotton wool spots BE disc pallor and macular odema

  14. OD no glaucomatous disc damage Follow-up – After 1 Month • OU • resolved macular edema • no active vasculitis

  15. Follow-up – After 1 Month

  16. Therapy Revision for OD • Mycophenolate mofetil 1500mg /day • Prednisolone 20mg /day • Brimonidine 0.2% and • Timoptol 0.5%

  17. Patient shifted her residence and got lost for follow up for 6 months

  18. Follow-up – After 6 months • OD • Extensive vascular occlusion • resolved macular edema • Advised FFA

  19. SEVERE VASCULAR OCCLUSION WITH MACULAR ISCHEMIA

  20. NVD on the optic disc

  21. Therapy updated • PRP in 3 sitings for the OS • after discussion with rheumatologists: • Trental as vasodilatator • 400mg BD 15 days

  22. Follow-up – After 7 months • presented with sudden onset defective vision since two days in OS

  23. Follow-up – Ocular Examination FOLLOW UP ON JUNE,14TH 2010

  24. Ocular Examination • pale optic disc • sclerosed vessels • CWS • premacular hemorrhage • Pars PlanaVitrectomy with C3F8 under GVP

  25. Treatment • PPV+C3F8 under guarded visual prognosis

  26. Follow-up – After 8 months • Treatment was continued with immummunosuppressives and topical Dorzolamide 2% for the OD

  27. Follow-up – After 9 months

  28. Treatment • diode cyclophotocoagulation in OD • vitreous lavage in OS • she failed to follow-up.

  29. autoimmune, non-organ specific connective tissue disorder • 20% have ocular involvement • 90% are women, mostly of child bearing age • all age groups and both genders affected • ocular activity may occur independent of systemic activity • Lupus retinopathy is an imp marker of disease activity • ocular inflammatory lesions may precede extraocular manifestation by several months Discussion

  30. Conclusion • Although ocular involvement is benign, potentially blinding complications may occur. • Lupus retinopathy and neuro-ophthalmic involvement suggest systemic activity, therefore referral to a RHEUMATOLOGIST for management is mandatory. • Early diagnosis and timely institution of systemic therapy may minimize morbidity and mortality.

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