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Optic neuritis (ReelDx + Lecture)

VIDEO-CASE-PRESENTATION-REEL-DX

Optic Neuritis

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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Optic neuritis is associated with what TB medication?
Ethambutol (a common board question) 

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

Picmonic
Multiple Sclerosis

multiple-sclerosis-symptoms-and-diagnosis_5975_1492145264

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
A 24-year-old woman with HIV is diagnosed with Mycobacterium avium complex infection. She is started on a treatment regimen of clarithromycin with ethambutol. She needs to be educated that which of the following is a potential complication of this therapy?
A
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.
B
azotemia
Hint:
Amphotericin B is associated with azotemia and trimethoprim with methemoglobinemia.
C
methemoglobinemia
Hint:
Amphotericin B is associated with azotemia and trimethoprim with methemoglobinemia.
D
mucositis
Hint:
Trimetrexate can cause mucositis.
E
optic neuritis
Question 1 Explanation: 
Optic neuritis is associated with the use of ethambutol. Anemia is associated with many of the drugs used to treat AIDS-related opportunistic infections, including trimethoprim-sulfamethoxazole, pentamidine, amphotericin B, ganciclovir, and valganciclovir. Amphotericin B is associated with azotemia and trimethoprim with methemoglobinemia. Trimetrexate can cause mucositis.
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References: Merck Manual · UpToDate

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