| Identifier |
walsh_2020_s1_c5 |
| Title |
Look in the Back (Video) |
| Creator |
Tatiana Deveney, Aristides Capizzano, Jonathan Trobe |
| Subject |
Herpes Zoster (Zoster Ophthalmicus), Vasculitides, Magnetic Resonance Imaging, Thyroid Eye Disease |
| History |
A 59-year old man with Graves disease developed increasing proptosis and diplopia. Attributing these abnormalities to worsening of the Graves disease, an ophthalmologist treated him with high-dose oral and intravenous corticosteroids. When improvement did not occur, he underwent orbital x-irradiation (unknown dose). He developed new bilateral hearing loss, bilateral lower extremity weakness, and urinary retention eliciting catheter placement. Visual acuity declined, so he was referred to our institution for urgent orbital decompression. When we first encountered him, he was confused and drowsy. Best-corrected visual acuity was 20/80 in the right eye and 20/200 in the left eye. There was no afferent pupillary defect. External examination revealed marked proptosis. Extraocular motility was reduced in all directions. There was marked superficial punctate keratopathy bilaterally. Ophthalmoscopy through dilated pupils revealed multifocal white/yellow subretinal lesions without vitreous cells in both eyes. He had bilateral sensorineural hearing loss and bilateral lower extremity weakness with diminished lower extremity deep tendon reflexes. Orbital CT revealed bilaterally enlarged extraocular muscles with fullness at the orbital apex but no clear compression of the optic nerves. Brain MRI revealed diffuse intracranial leptomeningeal enhancement and enhancement of both auditory canals. Additionally, there was; restricted diffusion in the left fornix and right putamen. Spine MRI revealed enhancement of the cauda equina roots. Lumbar puncture showed a normal opening pressure with a white blood cell count of 578 (78% lymphocytes), a protein of 348 mg/dL, and negative cytology. The leading diagnosis was non-Hodgkin lymphoma (NHL). The putaminal and fornix abnormalities, believed to be; consistent with ischemic stroke, led to more detailed review of the brain MRI, which disclosed vessel wall enhancement of the right internal carotid artery. A procedure was performed. |
| Disease/Diagnosis |
Multiple neurologic manifestations of VZV (ischemic brain parenchymal stroke, inflammation of the meninges, cranial nerves, nerve roots, and retina) in the setting of advanced Graves disease treated with high dose steroids. |
| Date |
2020-03 |
| References |
1) Song JW, Ojeda S, Romero JM. High resolution vessel wall MRI and vasculopathy related to herpes zoster ophthalmicus. Clin Imaging. 2018; 50:336-339. 2) Savoldi F, Kaufmann TJ, Flanagan EP, Toledano M, Weinshenker BG. Elsberg syndrome: A rarely recognized cause of cauda equina syndrome and lower thoracic myelitis. Neurol Neuroimmunol Neuroinflamm. 2017; 4: e355. 3) Lynch K, Agarwal P, Paranandi A, Hadley S, Vullaganti M. Extensive VZV Encephalomyelitis without Rash in an Elderly Man. Case Rep in Neurol Med. 2014;2014: 694750. 4) Nagel MA, Gilden D. Neurological Complications of Varicella Zoster Virus Reactivation. Cur Opin Neurol. 2014; 27:356-360. 5) Karma A, von Willebrand EO, Tommila PV, Paetau AE, Oskala PS, Immonen IJ. Primary Intraocular Lymphoma: Improving the Diagnostic Procedure. Ophthalmology. 2007; 114: 1372-1377. |
| Language |
eng |
| Format |
video/mp4 |
| Type |
Image/MovingImage |
| Source |
2020 North American Neuro-Ophthalmology Society Annual Meeting |
| Relation is Part of |
NANOS Annual Meeting 2020: Frank B. Walsh Session 1 |
| Collection |
Neuro-Ophthalmology Virtual Education Library - Walsh Session Annual Meeting Archives https://novel.utah.edu/Walsh/index3.html |
| Publisher |
Spencer S. Eccles Health Sciences Library, University of Utah |
| Holding Institution |
Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E SLC, UT 84112-5987 |
| Rights Management |
Copyright 2020. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright |
| ARK |
ark:/87278/s6md47jt |
| Setname |
ehsl_novel_fbw |
| ID |
1538211 |
| Reference URL |
https://collections.lib.utah.edu/ark:/87278/s6md47jt |
