《42 yo M with Blurred vision for 1+ week》由会员分享，可在线阅读，更多相关《42 yo M with Blurred vision for 1+ week（42页珍藏版）》请在金锄头文库上搜索。
1、42 y/o M with Blurred vision for 1+ week,R4 陳怡杏May 12th, 2011,EBM Case discussion,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, CADpersonal history: denied
2、alcohol, smoke, drug abuse history2+ year-foreign worker from Tailand,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:CF1MP: orthopupil: isocoric, MG(-)EOM: f & fConj: mild congestion, K: clear, AC : D/Cell+, Lens:
3、 clear color od 5/7 os 0/7,Fundus examination,Fundus examination,OCT,Tracing back his history,BP: 120/90mmhgarthritis (-), oral ulcer (-)Raised cat in Tailand (+), no cat scratch history,Papilledema+ macular star+seroud rd,Diagnosis?,Bil neuroretinitis d/d,Cat scratch disease cat contact history?Syp
4、hillis VDRL, TPHAHaradas diseaseSarcoidosis ACE, CXRToxoplasmosis Toxo IgG, IgMIdiopathic neuroretinitisLyme diseaseHypertensive retinopathy,CXR,Normal heart sizeTortuosity of thoracic aorta Infiltration at bil. lower lungs,LAB,post Cortrimazole 1wk,oct,FAG+ICG,FAG+ICG,FAG+ICG,FAG+ICG,FAG+ICG,FAG+IC
5、G,Neuroretinitis,First described by Leber in 1916characterized 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 leakageUsually unilateralCause: cat scratch disease 2/3,
6、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 macul
7、ar exudates,Macular exudation,Usually disc edema firstMacular exudation often manifests within 2-4 wks after disease onsetOften 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/oDisc edema: begins to dec
8、rease in 2 weeks and usually complete resolution in 8 to 12 wks,Neuroretinitis-pathogen,recurrent neuroretinitis,In the same/fellow/both eyesAccumulative visual loss after each episodeIncomplete recovery of visual function: due to permanent damage to the optic nerve, not the maculaPathogenesis: pati
9、ents without systemic disease may have immune disorder involving disc vasculature,Ach Ophthalmol. 2003; 121: 65-67J Neuro-Ophthalmol 2005;25: 286288,recurrent neuroretinitis,30 pt with recurrent NR, 7 pts had immunosuppresants (prednisone, azathioprine, or both)Attack rate decreased 72% after initia
10、tion of immunosuppressive therapy (0.58- 0.16 attacks/yr)Other disease association: Toxoplasmosis, melanocytoma, sarcoidosis, multiple sclerosis,Cat scratch disease-presentation,Most common :lymphadenitisAtypical forms: Parinaud oculoglandular syndrome, stellate neuroretinitis (10%), persistent feve
11、r without localizing signs, hepatosplenic infection, encephalopathy, osteomyelitis, and endocarditis,Cat-scratch disease,First described by Parinaud in 1889,Hiv in csd,seroprevalence of Bartonella in patients with HIV infection: 16% to 40%, but seropositivity does not correlate directly with evidenc
12、e of clinical infection,CSD-diagnosis,LN biopsy or conjunctiva biopsyIndirect fluorescent antibody (IFA) test: 88% sensative, 94% specificEnzyme immunoassay (EIA) IgG sensitivity 86-95%, specificity 96% compare to IFAPCR: amplify small fragment of bacterial 16S rRNA gene of Bartonella DNA,Treatment
13、of csd,Efficacy: Rifampin (87%), Ciprofloxacin (84%), gentamicin (73%) trimethoprim and sulfamethoxazole (58%)Penicillins, cephalosporins, tetracycline, and erythromycin had minimal or no clinical efficacyImmocompetants: rapidly responsive to many antibacterial agents, including those not felt to be
14、 effectiveImmunocompromised pts: gentamicin, macrolides, quinolones, and rifampin,Current Opinion in Pediatrics 2001, 13:5659,Optic neuritis/papillitis in csd,Cat-scratch disease has been confirmed as a cause of optic neuritis as well as neuroretinitis,49 y/o M, 21142522,CC: progressive blurred visi
15、on od for 3 months2011/03/01 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,Fundus exam,CT (-)CXR npLAB survey: WNL,Pre-tx (2011/3)Post- tx 3 day pulse therapy+doxycycline(2011/4/28),Rnfl thinning after neuroretinitis,#2001079941 y/o M, metamorphopsia (OD) since July 2010, grey color and then black,2010/7,2010/9,Since 2010/11,2010/11,2011/4,Oct initial-final,2010/7,2011/4,Thank you for your listening,
