Andrew R. Carey, J. Antonio Bermudez-Magner, Sander R. Dubovy, Norman J. Schatz, MD, Bascom Palmer Eye Institute; Linda L. Sternau, Byron L. Lam
Subject
Papilledema, Leptomeningeal Melanomatosis, Vision Loss, Headache, Magnetic Resonance Imaging
History
A 36 year-old man presented with severe headaches, bilateral leg numbness, and bilateral decreased vision. He was born in Ecuador where he received BCG vaccination and immigrated to US at age 19. In 2005 he enrolled in nursing school and volunteered in homeless shelters. PPD was positive with a negative chest x-ray. In August 2011 he developed pleuritic chest pain; chest x-ray showed a 2 cm cavitary lesion in the right upper lobe. He was diagnosed with active TB and completed treatment in August 2013. In December 2013 he developed headaches associated with neck stiffness and intermittent blurry vision which progressed over 6 months. In May 2014, while on vacation in Ecuador, he had a prolonged seizure requiring intubation. Upon recovery he returned to Florida and presented to the emergency department with visual loss and drowsiness, but arousable to verbal stimuli. Vision was light perception OU with sluggish pupils. Extraocular movements were full but demonstrated exotropia. Fundus examination showed papilledema. Strength was reduced in all four limbs with apraxia in the upper right. Sensation was decreased from groin to foot, left worse than right. Serum white count was elevated to 25,300. Brain MRI demonstrated hydrocephalus and diffuse leptomeningeal enhancement including bilateral intracranial optic nerves and chiasm. CSF analysis showed 110 leukocytes with 66% monocytes. Lumbar spine MRI was negative. The patient was diagnosed with recurrent TB with meningitis and was restarted on TB medications. CSF smears, cultures, and PCR were negative for infection including TB. Lumbar drain was placed and ICP was 40 cm water. Repeat brain MRI showed progressive leptomeningeal enhancement and hydrocephalus. Repeat CSF analysis demonstrated cellular atypia with equivocal immuno-histochemical staining. Flow cytometry revealed a mixture of immune cells but no B lymphocytes. A diagnostic procedure was performed.
Date
2015
Language
eng
Format
video/mp4
Type
Image/MovingImage
Relation is Part of
NANOS Annual Meeting Frank B. Walsh Sessions; 2015