Case Presentation

-Dr.Prathibha.M.C

Balaji .P ( OP: 1OP738997) 27 years, male, driver by occupation from Bangalore. Seen on 27/2/2012 and 29/2/2012 in sector OPD From 7/03/2012 @ retina clinic

Chief Complaints
On 27/02/2012 Difficulty while driving since 2 days Left eye decreased vision -2 days Left eye pain and redness- 2 days

History of presenting illness

Patient was apparently alright when he started having pain and redness associated with decreased vision which hampered his driving and he approached the eye doctor for the same. Decrease in vision- insidious in onset for both distance and near, and non progressive , associated with pain , no increase in pain with movement of eyes Pain was insidious in onset dull aching and constant , non radiating ,no associated headache or nausea or vomiting /no tinnitus/flashes of light/floaters Redness was not associated with any discharge/itching/watering

No- h/o trauma; h/o usage of contact lenses

h/o long term eye ocular medications h/o ocular surgery No h/o similar complaints in other eye /in the past

History of presenting complaints

H/o fever and myalgia, associated headache for which he was admitted in the general hospital for 1 week in the month of January first week No h/o rashes/joint pain/nausea or vomiting No h/o any blood transfusion/cough with expectoration/diarrhoea/constipation/convulsions No h/o weight loss No h/o using any long term medication in the past for any systemic illnesses

Personal history and family history

Unmarried; mixed diet Dyslexia+

Past medical and ocular history

Admitted recently for fever with myalgia and headache- investigated for the same No significant ocular history

Treatment history :during the stay in hospital was given IV ciplox

BD and IV metrogyl TID for 5 days with fluid replacement IV for 5 days followed by oral ciprofloxacin for 2 weeks with NSAID and vitamin substitute; investigated with baseline blood tests and urine and stools examination.

General physical examination

Moderately built well oriented to time place and person Height-6 feet Weight-68 kgs Pulse-76/min ; afebrile Blood pressue:126/68 mmhg

Ocular examination
Right Eye Vision- UCVA- Distance Vision UCVA- near Color vision Extraocular movementsductions and versions IOP- Perkins Head posture Facial symmetry Ocular symmetry Lids and adnexa Lacrimal sac area 6/6 N6 normal normal 12 mmhg normal normal normal Normal Roplas -ve Normal Roplas -ve Left eye Pl+/Pr- accurate/HM+/ CF- 1 meter ; pin hole - NI nil Not possible normal 6 mmhg

Right Eye

Right Eye

Right Eye

LEFT Eye

LEFT Eye

LEFT Eye

Ocular examination
Right eye Conjunctiva-bulbar and forniceal Cornea-size Shape Transparency sensation Anterior chamber depth content Iris & Pupil- position size Shape Reaction to light:direct and indirect Lens Normal normal Left eye Circumciliary congestion + Clear No edema No KP Normal sensation +2 cells +2 flare; single fibrinous strand+ at the pupil edge Normal Irregular from 6k to 10k Sluggishly reactive

normal

Normal Normal Normal Present and brisk Clear and normal

Clear; syneachia and pigment deposition+ +2 cells

Anterior vitreous(retrolental) Clear and normal

Fundus examination
78D Indirect ophthalmoscopy

Provisional diagnosis
Right eye: normal Left eye: Panuveitis with Neuroretinitis (acute and insidious)

Differential diagnosis
Acute febrile illness Chronis tuberculosis;syphillis;mycotic infection;parasitic(tenia) Retinal periphlebitis (?eales) Leptospirosis Lymes(borrelia burgdoferi) Bartonella hensale Rickettsia (r.Rickettsia;tsusugmushi) Toxoplasmosa retinitis Toxocara Cytomegalovirus retinitis Behcets disease

Investigations
Blood tests- complete blood count with smear Chest x-ray Mantoux test VDRL HIV-ELISA Weil Felix test Fundus fluorescein angiogram Optical coherence tomography

Investigations done
Hb%: 11gm% Total WBC: 7500cells/cmm Differential count :N:33%;L:59%; E:2%;M-1% CRP : - ve ESR; 16mm @30 min RBS:121mg/dl WIDAL test- negative(Jan) HIV tridot test- Negative(Jan) VDRL- not done WEIL Felix test- OX2 titers+ for R .Rickettsia(1:160) Mantoux test (5 mm) negative Blood Urea: 25mg/dl S.Creatinine; 0.4mg/dl

FFA Choroidal phase Arterial phase Early Arterio venous phase Arteriovenous phase Late arteriovenous phase Recirculation phase

Choroidal phase

Arterial phase

Early AV phase

AV phase

Late phase

Periphery no e/o sheathing or nve

Optic disc staining pattern

Right eye

Final diagnosis
Right Eye: Normal Left Eye: Retinitis with optic disc edema with serous retinal detachment and spill over anterior uveitis and vitritis secondary to post febrile illness(? Rickettsial)

Treatment
Tab Azithromycin 500 mg BD 1 week Tab Doxycycline 100 mg BD 2 weeks. Tb.Wysolone:60mg 1week tapering dose for next 6 weeks Topical : Homide e/d TID Predmet e/d 1hourly 1 week tapering 12/8/6/4/3/2 Oflacin e/d 4t/day

10 days after azithromycin