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Outcome:
When we obtained confirmation that the spinal fluid
was noninfectious, we began Solu-Medrol
(methylprednisolone) therapy, 1 g daily—since the
patient had lost vision in her only eye—and continued the medical
evaluation. Within 12 hours, the pain subsided—for the first time
in 10 months—vision improved to 20/25, and the patient correctly
identified 10 of 10 Ishihara color plates. Further evaluation showed
a negative PPD; the anergy panel showed no cutaneous response; the pulmonary
function tests showed diminished diffusing capacity; 24-hour urine calcium
levels were elevated, and the gallium scan showed increased bilateral
parenchymal uptake. All of these findings are indicative of sarcoidosis.
This patient has refused to undergo bronchoscopy to obtain histologic
confirmation of sarcoidosis.
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Summary:
The presence of periphlebitis at the 11-o’clock
position during the initial fundus examination led us to suspect
sarcoidosis as the most probable disorder in
our differential diagnosis. The MRI scans also revealed clinical findings
consistent with sarcoid. The optic nerve showed “stem to stern”
enlargement and was enhanced from the globe to the optic chiasm; a lumpy,
nodular-like enlargement of the contralateral posterior optic nerve
and intrinsic chiasmal expansion were noted. The patient showed no signs
of clear-cut lacrimal, meningeal, or hypothalamic enhancement or pituitary
stalk involvement, which are among the other classic MRI findings for
sarcoidosis involving the anterior visual pathway. Lymphocytic pleocytosis
was typical.
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