Lecture
Picmonic
50 y/o with pain and loss of vision in the left eye
Patient will present as → a 47-year-old school teacher with a cough, hemoptysis, fever, chills, and weight loss that has persisted since he returned from a summer trip to China. A chest radiograph is concerning for infection and a sputum culture is positive for acid-fast organisms. Treatment for this patient's condition is begun. Three weeks later the patient returns to the clinic with decreased visual acuity for one day in his right eye. He also reports pain in the eye with movement but no other symptoms. The patient has a family history of glaucoma, diabetes mellitus, factor V Leiden and stroke. On physical examination, when a penlight is shined into the affected eye there is no pupillary constriction in either eye.
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Acute inflammation and demyelination of the optic nerve leading to acute monocular vision loss/blurriness and pain on extraocular movements
- Pt will present with acute monocular vision loss and pain in the affected eye
- Typically occurs over hours or days
- Multiple sclerosis is the most common cause and optic neuritis is often the initial presenting symptom
- Optic neuritis is associated with the use of ethambutol (a common board question)
Fundoscopy: Inflammation of the optic disc
- MRI will confirm demyelination
Treatment is with methylprednisolone IV with a referral for neurology examination
Multiple sclerosis (MS) is a demyelinating disorder that demonstrates unclear pathogenesis but has significant evidence of autoimmune involvement. Clinical presentation is variable with subtypes delineated by symptom exacerbation, but it classically presents with Charcot’s neurologic triad, which consists of scanning speech, internuclear ophthalmoplegia, and nystagmus, with symptoms characteristically worsening after a hot shower. However, a wide range of clinical manifestations may be seen including optic neuritis, urinary, and fecal incontinence, motor abnormalities such as trembling and paresis, sensory changes ranging from pain to numbness and depression, all of which typically, though not exclusively, display a relapsing pattern. Diagnosis of MS includes the gold standard presence of simultaneous periventricular plaques on MRI, as well as elevated CSF immunoglobulins, most commonly IgG, and finally identification of oligoclonal IgG bands on immunoelectrophoresis.
| MS Symptoms and Diagnosis | Play Video + Quiz |
| MS Features and Mechanisms | Play Video + Quiz |
Question 1 |
anemia Hint: Anemia is associated with many of the drugs used to treat AIDS-related opportunistic infections, including trimethoprim-sulfamethoxazole, pentamidine, amphotericin B, ganciclovir, and valganciclovir. | |
azotemia Hint: Amphotericin B is associated with azotemia and trimethoprim with methemoglobinemia. | |
methemoglobinemia Hint: Amphotericin B is associated with azotemia and trimethoprim with methemoglobinemia. | |
mucositis Hint: Trimetrexate can cause mucositis. | |
optic neuritis |
Question 2 |
Diabetic retinopathy Hint: Typically presents with gradual vision loss and is not associated with pain on eye movement. | |
Glaucoma Hint: Causes gradual peripheral vision loss and is not typically painful. | |
Multiple sclerosis | |
Hypertensive retinopathy Hint: Associated with chronic hypertension and does not usually present with acute vision loss and pain on eye movement. | |
Retinal detachment Hint: Presents with flashes, floaters, and a "curtain" over the field of vision, without pain. |
Question 3 |
Fundoscopic examination Hint: May be normal in optic neuritis or show optic disc swelling. | |
MRI of the brain and orbits with gadolinium | |
Visual field testing Hint: Useful but not definitive for diagnosing optic neuritis. | |
Intraocular pressure measurement Hint: More relevant in glaucoma. | |
Fluorescein angiography Hint: Used in retinal vascular disorders, not typically in optic neuritis. |
Question 4 |
High-dose intravenous corticosteroids | |
Oral corticosteroids Hint: Not recommended as initial monotherapy for optic neuritis due to potential for recurrence. | |
Observation without treatment Hint: Not ideal for acute optic neuritis, as prompt treatment can aid faster recovery. | |
Intravitreal corticosteroid injection Hint: Not a standard treatment for optic neuritis. | |
Immunosuppressive therapy Hint: Considered in cases of recurrent optic neuritis or associated autoimmune disorders. |
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List |
References: Merck Manual · UpToDate