Spots, Spots Everywhere, And Not A Spot To See

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Identifier walsh_2013_s3_c5
Title Spots, Spots Everywhere, And Not A Spot To See
Creator Sarkis M. Nazarian; Kelli Y. Shaon; Kenneth R. Habetz; Ayman Al-Salaimeh; John D. Schwankhaus; Joseph G. Chacko
Affiliation (SMN) (KRH) (AA) (JDS) (JGC) University of Arkansas for Medical Sciences, Little Rock, AR; (SMN) (AA) (JDS) (JGC) Central Arkansas Veterans Healthcare Center, Little Rock, AR; (KYS) Veterans Healthcare Center of the Ozarks, Fayetteville, AR; (KRH) Arkansas Childrens Hospital, Little Rock, AR
Subject Optic Nerve Vasculitis; Optic Neuropathy; Rocky Mountain Spotted Fever
Description Additional history revealed that the patient had suffered a tick bite about two weeks prior to the onset of his rash. Based on this information and the rash, patient was started on doxycycline and Rocky Mountain Spotted Fever (RMSF) titers were obtained; IgG by EIA was positive; confirmation by IFA was positive at 1:64 dilution. A week later, RMSF IgG IFA titer was positive at 1:256 dilution. Laboratory studies to rule out NMO (Neuromyelitis Optica), vasculitis, lupus, sarcoidosis, toxoplasmosis, syphilis, Brucellosis, Ehrlichiosis, etc. were all negative. Diagnosis of RMSF was made. The patient was treated with doxycycline 100 mg orally every 12 hours for 60 days. RMSF is a disease caused by R. rickettsii, an obligate intracellular coccobacillus spread by a tick vector. It manifests after a mean incubation period of 7 days with the triad of high fever, myalgia, and headache. Gastrointestinal manifestations are common. A centripetal rash starts in the wrists and ankles by days 3-7, and characteristically also spreads centrifugally to the palms and soles. It frequently can lead to CNS manifestations, including encephalitis, deafness, stroke-like syndromes, and encephalopathy. Ocular manifestations include conjunctivitis, anterior uveitis, retinal vasculitis, hemorrhages, and arterial occlusions. About 1.5% of reported cases have involved swelling of the optic nerves. A case report of macular star figure has been reported. Case reports generally are not favorable for good recovery of vision after optic nerve involvement. Prior to the antibiotic era, it was a highly lethal disease, but it responds to tetracycline, doxycycline, and chloramphenicol.
History Additional history revealed that the patient had suffered a tick bite about two weeks prior to the onset of his rash.
Pathology Rocky Mountain Spotted Fever (RMSF) titers were obtained; IgG by EIA was positive; confirmation by IFA was positive at 1:64 dilution. A week later, RMSF IgG IFA titer was positive at 1:256 dilution. Laboratory studies to rule out NMO (Neuromyelitis Optica), vasculitis, lupus, sarcoidosis, toxoplasmosis, syphilis, Brucellosis, Ehrlichiosis, etc. were all negative.
Disease/Diagnosis Optic neuropathy due to Rocky Mountain Spotted Fever
Clinical Erythematous rash that started on his back, spread centrifugally into his extremities, sparing his palms and soles, a couple of weeks before his vision declined. He had concurrent headache, fever, and generalized malaise. The rash had been diagnosed as a heat rash due to exposure to extreme heat while working on his farm.
Presenting Symptom A 58-year old man presented to the Eye Clinic at his local Hospital after his private Ophthalmologist found bilateral optic nerve edema as the cause of his sudden, painless binocular vision loss.
Neuroimaging CT Scan; MRI
Treatment Corticosteroid; Lumbar Puncture; Glaucoma Eyedrops; Doxycycline
Date 2013-02
References 1. Vaphiades MS. Rocky Mountain Spotted Fever as a cause of macular star figure. J Neuro-ophthalmol 2003 Dec; 23(4):276-278. 2. Dantas-Torres F. Rocky Mountain spotted fever. Lancet Infect Dis 2007 Nov; 7(11):724-732. 3. Helmick CG, Bernard KW, D'Angelo LJ. Rocky Mountain spotted fever: clinical, laboratory, and epidemiologic features in 262 cases. J Infect Dis 1984; 150:480-485. 4. Kim JH, Durack DT. Rickettsiae and the central nervous system. In Schild WM, Whitley RJ, Durack DT, editors: Infections of the Central Nervous System. New York; Raven Press 1991;411-424. 5. Vaphiades MS. Rickettsiae, Rickettsia-like organisms and the diseases they produce. In Miller NR, Newman NJ, Biousse V, Kerrison JB, editors: Walsh & Hoyt's Clinical Neuro- Ophthalmology. Philadelphia; Lippincott, Williams, and Wilkins; page 3050-3052.
Language eng
Format application/pdf
Type Text
Source 45th Annual Frank Walsh Society Meeting
Relation is Part of NANOS Annual Meeting 2013
Collection Neuro-Ophthalmology Virtual Education Library: Walsh Session Annual Meeting Archives: https://novel.utah.edu/Walsh/
Publisher North American Neuro-Ophthalmology Society
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah
Rights Management Copyright 2013. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
ARK ark:/87278/s6ms6qdc
Setname ehsl_novel_fbw
ID 179154
Reference URL https://collections.lib.utah.edu/ark:/87278/s6ms6qdc