Systemic Disorders With Optic Nerve and Retinal Findings

A 42-year old woman presented with a history of severe brow pain and 4 days of progressive visual loss OD. There was no increased pain on ocular rotation. Aside from heavy menses, she denied any significant past medical history. Her examination revealed acuity NLP OD, 20/25 OS; color vision 9/10 OS; pupils amaurotic OD, RRL OS, +3 APD OD; motility normal, slit-lamp examination and IOP normal OU; visual field mild generalized constriction and nasal step OS. Neurologic examination normal; funduscopic examination bilateral hyperemic disc edema, OD>>OS. The MRI of the head was normal. That night, she underwent a spinal tap that showed an opening pressure of 300, 5 white cells, protein = 30, and serology, cultures, and gram stain all negative. MRI of the orbits with fat suppression revealed enhancement of the right optic nerve and streaky enhancement of the orbital fat, consistent with optic neuritis/perineuritis. Her RPR returned later that day, and was +1:32, with a positive FTA-ABS. She was treated with 2 grams IV penicillin q4h for 14 days with concomitant Solu-Medrol 250 mg IV q6h for 3 days. Her pain resolved within 6 to 12 hours, and her vision recovered to 20/20 OU. She refused HIV testing and any subsequent blood work.