Case Report: Tropheryma whipplei Infection Presenting with Optic Disc Edema.

SIGNIFICANCE: Whipple disease is a rare chronic, systemic bacterial infection that predominantly affects the small intestine but also other organs of the body. When left untreated, it can be not only vision threatening but also life threatening because of its central nervous system involvement. Therefore, early detection and treatment are important. PURPOSE: We report a rare case of unilateral optic disc edema as a critical identifying sign of Whipple disease. CASE REPORT: An asymptomatic 49-year-old African American man presented for an eye examination and was found to have optic nerve edema of the right eye. His best-corrected visual acuity was 20/20 in the right and left eye. He denied symptoms of diplopia, amaurosis fugax, or eye pain. His medical history was significant for HIV with no recent detectable viral load at the time of his eye examination. The patient denied any other infectious risk factors or changes in medical status. Extensive ophthalmic, neuroimaging, and laboratory investigations were completed as a comprehensive approach to rule out more common etiologies for unilateral optic disc edema. This initial workup yielded no identifying etiology, and the patient was monitored closely with frequent examinations with a retina specialist. Soon after his diagnosis of optic nerve edema, the patient developed new symptoms of chronic diarrhea, weight loss, and fatigue requiring hospitalization. Evaluations by internal medicine and gastroenterology, including serological testing, stool analysis, histological and microbiological analysis, esophagogastroduodenoscopy, and gastrointestinal biopsy, confirmed a diagnosis of Whipple disease that was successfully treated with oral antibiotics. CONCLUSIONS: Whipple disease is a rare cause of infectious optic nerve edema that may present with other rheumatoid and gastrointestinal symptoms. A comprehensive medical approach for investigating unilateral optic nerve edema is paramount in diagnosing and treating Whipple disease.

More than meets the eye: Papilledema from syphilis posing as idiopathic intracranial hypertension.

Idiopathic intracranial hypertension (IIH), or pseudotumor cerebri, is a diagnosis of exclusion. Elevated intracranial pressure (ICP) can result from a variety of inflammatory and structural causes affecting cerebrospinal fluid production and absorption. First described in 1935, syphilis is a well-established cause of elevated ICP, referred to as syphilitic hydrocephalus. We report a case of a 49-year-old man presenting with vision changes and headache who was treated for IIH without resolution of symptoms, and eventually diagnosed with syphilitic hydrocephalus. Syphilis should be considered as a cause of elevated ICP prior to a diagnosis of IIH.

Subacute transverse myelitis with optic symptoms in neuroborreliosis: a case report.

BACKGROUND: Subacute transverse myelitis is one of the late manifestations of neuroborreliosis with only a few cases described to the present day. CASE PRESENTATION: We present magnetic resonance imaging, cerebrospinal fluid, and electroneurography findings of a young female patient suffering from neuroborreliosis-associated transverse myelitis with a wide constellation of symptoms including papilloedema. Magnetic resonance imaging of the cervical spine has shown an enlargement of the spinal cord in the mid-cervical region. Cerebrospinal fluid findings included lymphocytic pleocytosis, increased levels of anti - Borrelia antibodies, and increased intrathecal anti -Borrelia antibody index. Following the 28-day course of intravenous ceftriaxone, the patient attained complete recovery. CONCLUSIONS: Subacute transverse myelitis in the course of neuroborreliosis should be considered in the differential diagnosis of patients with abnormal magnetic resonance scans of the spinal cord, lymphocytic pleocytosis, and intrathecal antibody production, especially in the tick-endemic areas, even if the tick bite was not reported. Infrequent accompanying symptoms such as papilloedema are diagnostically challenging and cannot be treated as clinching evidence.

Papilitis por citomegalovirus en niña con leucemia linfoblástica aguda / Cytomegalovirus papilitis in a child with acute lymphoblastic leukemia

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Diagnosis of Syphilitic Bilateral Papillitis Mimicking Papilloedema.

Syphilis produces myriad nonspecific signs and symptoms. For example, optic disk swelling might be seen in patients with syphilis as a result of cranial hypertension (papilloedema), inflammatory optic neuritis with papillitis, or optic perineuritis. We report a case involving differential diagnosis of syphilitic bilateral papillitis mimicking papilloedema.

Tubercular posterior scleritis: A case report and review of literature.

A 47-year-old female presented with optic disc oedema, peripapillary subretinal fluid and scattered areas of choroiditis. Her ultrasound B-scan showed sclerochoroidal thickening with widening of sub-Tenon space. Subsequent investigations revealed a positive Mantoux test and high-resolution computed tomography of the chest was suggestive of pulmonary involvement. She responded well to antitubercular treatment and systemic corticosteroid. A review of the literature was conducted to identify additional reports on similar cases and discussed. A high index of suspicion and appropriate laboratory work-up can aid in the diagnosis of tuberculous posterior scleritis.

Raised intracranial pressure with bilateral anterior uveitis.

We report the rare case of a 5-year-old boy with an infective cause of papilloedema and bilateral uveitis secondary to Mycoplasma pneumoniae The patient presented with generalised headache and malaise. MRI showed signs of raised intracranial pressure and lumbar puncture opening pressure was 43 cmH2O.Lumbar puncture did not reveal any infective organisms. Blood tests showed raised inflammatory markers. The patient was started on prednisolone, acetazolamide and intravenous cefotaxime. Following an improvement, the patient was discharged.However, the patient re-presented 2 weeks later with bilateral anterior uveitis. With the combination of papilloedema and bilateral uveitis, M. pneumoniae infection was suspected. Tests confirmed recent mycoplasma infection. Topical dexamethasone and oral azithromycin were given and symptoms improved.Vision remained normal throughout. At 1-year follow-up, the patient remains well. The authors would like to highlight a rare infectious cause of papilloedema in young children.

[Skin and mucosal erosions revealing secondary syphilis with otologic and eye disorders]. / Érosions cutanéo-muqueuses révélant une syphilis secondaire avec atteintes otologique et ophtalmologique.

BACKGROUND: The clinical polymorphism of syphilis leads to diagnostic issues. We report a case of secondary syphilis revealed by skin and mucosal erosions, and responsible for sensorineural hearing loss and asymptomatic papillitis. PATIENTS AND METHODS: A 55-year-old man presented oral and peri-anal erosions as the initial symptoms of secondary syphilis. He reported hypoacusis and a pure-tone audiogram revealed bilateral sensorineural hearing loss. Ophthalmological investigation revealed isolated right papillitis and superior temporal scotoma with blind-spot enlargement. TPHA-VDRL serology was strongly positive for plasma (TPHA 1/10,240 and VDRL 1/64) but doubtful for cerebrospinal fluid. For his hearing and eye disorders, considered as related to neurosyphilis, the patient received a 14-day course of intravenous penicillin G, associated with systemic corticosteroids with gradual reduction over a period of fifteen weeks. The patient's skin and mucosal erosions resolved, as did his papillitis. His hearing loss remained stable. Serological monitoring at three months showed a sixteen-fold decrease in VDRL titre. DISCUSSION: The re-emergence of syphilis has led to increasing incidence of related ophthalmological and otological disorders. This report highlights the first-line role of the dermatologist in systematic diagnosis and in screening for associated involvement.

Acute Mycoplasma pneumoniae infection presenting with unilateral anterior uveitis and perineuritis.

We report a case of confirmed Mycoplasma pneumoniae infection in the setting of unilateral anterior uveitis and perineuritis without coexisting systemic manifestations. We hypothesize a causal association between acute M. pneumoniae infection and this patient's ocular presentation. Delay in identification of M. pneumoniae infection in this case prompted treatment with systemic and topical steroids for presumed autoimmune etiology. The rapid resolution of symptoms without concurrent antibiotic treatment suggests a possible postinfectious autoimmune component that may be responsive to steroid treatment.

[Eye and cat scratch disease: A case series]. / Œil et maladie des griffes du chat : à propos de 7 cas.

INTRODUCTION: Cat scratch disease is a pleiomorphic condition, sometimes with isolated ophthalmic involvement. We report the clinical observations of seven cases with ophthalmologic manifestations of cat scratch disease. OBSERVATIONS: There were seven patients, with a median age of 52 years, of whom five were women and three had unilateral involvement. Six exhibited Leber's stellate neuroretinitis, an incomplete syndrome in two cases, and one associated with chorioretinal foci. One patient had isolated retinal infiltrates. The diagnosis of cat scratch disease was confirmed by Bartonella henselae serology, positive in all cases. All patients received treatment with doxycycline. Ocular complications (with optic atrophy and macular retinal pigment epithelial changes) were noted in five cases. DISCUSSION: Ocular bartonellosis is an atypical clinical form. It requires a directed ancillary work-up with serology or PCR, which has the peculiarity of being highly specific if not very sensitive. Treatment is above all preventive. Antibiotics may be initiated. CONCLUSION: Cat scratch disease must be excluded in the work-up of posterior uveitis.

[A Japanese case of neuroborreliosis with papillitis].

A 53-year-old Japanese female developed a fever about two months after a tick bite. She also exhibited blurred vision, central scotoma in the left eye, left facial paresis and mild ataxia. A fundus examination revealed left disc swelling in the left eye. An ophthalmological examination showed decreased visual acuity with central scotoma in the left eye. We suspected neuroborreliosis because of the presence of pleocytosis and an elevated level of IL-6 in the cerebrospinal fluid (CSF), in addition to the characteristic neurological findings. She was positive for serum IgG antibodies against Borrelia by a Western blot of her serum. Therefore, we diagnosed her to have neuroborreliosis with papillitis. After the combined administration of antibiotics and steroids, her symptoms gradually improved, but not all of her eye manifestations resolved. Although ocular involvement is rare in neuroborreliosis, this case highlights the fact that neuroborreliosis shoud be considered as a differential diagnosis for patients presenting with papillitis. The diagnosis of neuroborreliosis is important since improvement of the visual acuity is possible with specific antibiotheraphy. In cases with papillitis of unknown etiology, it might be better to consider the possibility of neuroborreliosis should be considered when there are signs of Lyme borreliosis, such as facial nerve palsy, arthritis or radiculoneuritis.

A 31-year-old man with bilateral blurry vision and floaters.

We report a case of bilateral multifocal retinochoroiditis and bilateral optic disc edema in a patient with cat-scratch disease from Bartonella henselae. The patient initially had negative serologic testing. Repeat testing showed a markedly increased IgG and IgM convalescent titer and the development of a branch retinal artery and vein occlusion. In patients for whom there is a high clinical suspicion of cat-scratch disease, a convalescent titer should be obtained 2-3 weeks following a negative initial result.

Neuro-ophthalmic presentations and treatment of Cryptococcal meningitis-related increased intracranial pressure.

OBJECTIVE: To illustrate three different ophthalmic presentations of cryptococcal meningitis (CM). INTRODUCTION: CM is the most common manifestation of extra-pulmonary cryptococcosis. Intracranial hypertension occurs in up to 75% of patients with CM and is associated with increased mortality. CM can present to the ophthalmologist as vision loss, papilledema, abducens palsy, and/or other cranial neuropathies. PARTICIPANTS AND METHODS: We report three cases, two C. neoformans and one C. gattii, highlighting the various CM presentations. The first was a woman immunosuppressed following kidney transplantation in whom idiopathic intracranial hypertension (IIH) was initially suspected. The second was a man immunocompromised by previously undiagnosed HIV/AIDS who presented with signs and symptoms of increased intracranial pressure. The third case is an immunocompetent man with bilateral disc edema and an incomplete macular star diagnosed with presumed neuroretinitis. Further evaluation revealed positive CSF cryptococcal antigen with culture positive for C. gattii. CONCLUSIONS: Ophthalmologists should be aware that cryptococcosis can mimic more benign etiologies including IIH and neuroretinitis. Additionally, C. gattii, an emerging organism, can infect immunocompetent patients. In contrast to the typical treatment of increased ICP, serial lumbar punctures are recommended while acetazolamide and surgical CSF shunting may be harmful.

Papilitis por infección del virus de Epstein-Barr en paciente adulto / Papillitis due to Epstein-Barr virus infection in an adult patient

Caso clínico: Mujer de 70 años que consultó por dificultad de visión en ojo derecho de 2 semanas de evolución. Presentaba una agudeza visual (AV) de 0,6 y 1,0 con polo anterior y presión intraocular normales y defecto pupilar aferente relativo. En el fondo de ojo se apreciaba papilitis en ojo derecho. Los elevados valores de reactantes de fase aguda condujeron al diagnóstico inicial de neuritis óptica isquémica anterior arterítica (NOIA-A) iniciándose tratamiento con corticoides. Discusión: Según la edad de la paciente, la funduscopia y los elevados valores de los reactantes de fase aguda, el diagnóstico inicial fue de NOIA-A. Sin embargo, las características de papilitis atípica, con buena AV y campimetría inespecífica, una adecuada historia clínica y el cuadro general de características víricas, con su confirmación analítica, condujeron al diagnóstico de papilitis por primoinfección por virus de Epstein-Barr, cuadro muy poco frecuente debido a la edad avanzada de la paciente (AU)

Case report: A 70-year- old woman who consulted due to poor vision in her right eye for 2 weeks. The examination showed a visual acuity (VA) of 0.6 and 1.0, with normal anterior pole and intraocular pressure and a relative afferent pupillary defect. Some papillitis was observed in the fundus of her right eye. The high levels of acute phase reactants led to an initial diagnosis of arteritic anterior ischemic optic neuropathy (AAION) and treatment with corticosteroids was started. Discussion: According to the age of the patient, the fundus and the high levels of acute phase reactants, the initial diagnosis was AAION. However, the atypical papillitis features, with good AV and non-specific perimetry, together with a suitable medical history, and a profile of viral characteristics, with laboratory confirmation, led to the diagnosis of a primary papillitis infection due to Epstein-Barr virus, a very rare case due to the advanced age of the patient (AU)

Ocular involvement of brucellosis.

A 29-year-old male diagnosed with brucellosis a week earlier was referred to the ophthalmology clinic with visual complaints. On examination, visual acuity was 20/25, he had conjunctival injection on slit lamp examination. There was also bilateral optic disk swelling plus retinal hyperemia (optic disc hyperemia and vascular tortuosity) and intraretinal hemorrhage on funduscopy. The patient was admitted and treated with cotrimoxazole, rifampin, doxycycline and prednisolone for 2 months. Ocular manifestations subsided gradually within 6 months after treatment. Brucellosis can affect the eye and lead to serious ocular complications. Early diagnosis and prompt treatment should be considered in endemic areas.

[A case report of syphilitic uveitis and deafness]. / Uvéite syphilitique et surdité : à propos d'un cas.

We report the case of a 43-year-old male patient presenting for neuro-ophthalmologic and uveitis consultation at Clermont-Ferrand University Medical Center for a reduction in visual acuity in his right eye. Two months previously, the patient had complained of decreased hearing on the left, which remained undiagnosed. Fundus examination and fluorescein angiogram showed the appearance of vasculitis with papillitis and a choroidal plaque. TPHA-VDRL serology was positive in blood and cerebrospinal fluid. Internal medicine work-up revealed many associated abnormalities: hyperhomocysteinemia, positive anticardiolipin antibody, positive anti-ß2GP1 antibodies, increased partial thromboplastin time not corrected by the addition of control plasma, presence of an anti-prothrombinase antibody, positive activated protein C resistance. ENT examination showed a left harmonic vestibular syndrome; audiography showed a sensorineural hearing loss of -40 dB. The patient received treatment for neurosyphilis, which led to the disappearance of the vasculitis, the choroidal plaque and the papillitis. From an ENT standpoint, the vestibular syndrome and the left vestibular areflexia resolved. The audiogram improved, with persistence of left hearing loss (about -20 dB) with useful speech intelligibility. Immunologic abnormalities had also disappeared. Our case illustrates the protean presentations of syphilis and its possible association with sensorineural deafness and immunological abnormalities.