History
5 year old girl K.R. referred for fundus examination
Present Hx:
Sudden loss vision of BE of 3 & ½ weeks
Intermittent headache for 4 moths
Seen by Pediatricians  in Gisborne Hospital
PMHx: Nil
Investigations showed normal FBC,U’s+E,liver function and serum lead level,glucose. LP:normal cell count & protein,CSFP:23cm. CT head normal.
History
Ocular examination at then:
Corrected VA 6/30 R& L
Bilateral swelling discs
Normal VF
Diagnosis: Idiopathic Intracranial Hypertension (IIH)
Treatment includes 2 weeks of:
Systemic Acetazolamide,Frusemide &Steroid
Repeated release of CSF

History
No improvement of VA & persistent papilloedema.
Transferred to Starship Hospital for Rx,8/08/00.
Shunting procedure to lower CSF Pressure was proposed.
Referred to AKH Ophthalmology service on 10/08/00 for funds examination.
Eye examination AKH
Perfectly healthy child
VA:6/24OU,no improvement č; PH
No RAPD
Full color vision
VF: enlarged blind spots both eyes
Quite anterior segments
Ocular motility: full
Eye exam. ( cont.)
Fundi exam.: see attached pictures

Question: 1. Your diagnosis or differential diagnosis
Question: 2. Your proposed work up of this patient

see you later

［打包下载］　　　［引用该文］　　　［发表评论］　　　［转寄该文］　　　［关闭窗口］

此文章相关评论:

该文章有8个相关评论如下：(点这儿论坛方式查看)

shuandai	发表于： 2003/10/13 08:48pm
	Sorry. The history should be: "sudden loss of vision of both eyes for 3 and half weeks."
顶部

哨哨嘟嘟	发表于： 2003/10/13 11:30pm
	开始我以为是视神经视网膜炎呢．．我怎么也不会想到是自发性颅内高压引起的．．但是双眼视神经水肿我会考虑建议作颅脑ｃｔ的．．不过不会想到查脑脊液的．．呵呵．．学习了．． 难道还有其它诊断？提示一下．．
顶部

2002yxy	发表于： 2003/10/15 03:53pm
	[这个贴子最后由2002yxy在 2003/10/15 11:57am 编辑] 本人还认为是 neuroretinitis，依据：1。相关因素：儿童，秋季，高颅压，头痛                                   2。视力急降                                   3。视乳头边界糊，后极部大量水肿渗出，视野呈生理盲点扩大状                             鉴别诊断：视乳头水肿，视乳头血管炎等                         治疗：  病因＋激素＋vitB    拙见，请赐教！
顶部

shuandai	发表于： 2003/10/29 04:06pm
	Excellent. This child indeed has bilateral neuroretinitis. Findings supportive of this diagnosis are: reduced vision; optic disc swelling, macular star exudates. findings not supportive of papilloedema are: loss of central vision which only ocurs in late stage of papilloedema. Can you or anyone be more specific with the diagnosis.
顶部

2002yxy	发表于： 2003/10/31 02:42pm
	请问血管扩张剂是否可用于neuroretinitis？ 请问  ShuanDai   对此病的治疗体会？
顶部

shuandai	发表于： 2003/10/31 09:27pm 相关图片如下：
	This child has bilateral neuroretinitis, previously most would use the term Leber's idiopathic stellate neuroretinitis. Recently, Bartonella Henselae has been identified as the organism causing this type of neuroretinitis. It is also called Cat Scratch Disease. It is much more common than previously thought. It is a self limited disease process which commonly cause headache, loss of vision and raised intracranial pressure. Treatment often not necessary and majority recover their vision in 6-8 weeks. Children with significant encephlitis may require antibiotics treatment such as doxycycline,or erythromycin. We ophthalmologist have a pivitol role to ascertain the diagnosis to avoid unneccessary investigation and treatments. We should also share our experience with our paediatrician colleagues, so they are aware of such common diseases. I will attach some paragraphy of my published paper on this child and the discussion about cat scratch disease associated neuroretinitis. I hope it will be useful. Further History about this child: K.R.’s family has 2 cats and 3 kittens She had close contact the cats and kittens prior to her illness No recall of being scratched by cat, or kittens Diagnosis ? Serum Bartonella Henselae titre( IgG 1024) highly positive. Bilateral Neuroretinitis associated with Cat    Scratch Disease Treatment ? Discharge & discontinued all medications Ophthalmology R/V 4 weeks later AKH 6 weeks later Systemically well VA: OD 6/9; OS 6/12+ Fundi exam.: Any changes in the discs & macula ? Discussion Leber’s Idiopathic Stellate Neuroretinitis. 1916. Unilateral Stellate macular exudates Unknown etiology Spontaneous resolution Dreyer et al 1984; modified the terminology of LISN, suggesting a heterogeneous group of conditions can cause similar clinical pictures. He also pointed out that it can be bilateral.many of Leber’s cases may indeed caused by CSD. Discussion ( cont.) Secondary causes of Neuroretinitis: Viral:hepatitis B,HSV,HZV,EBV influenza Bacterial:Bartonella(CSD),TB,Syphilis,lyme disease Fungi:histoplasmosis Parasites & protozoa: toxoplasmosis Others: sarcoidosis, Behcets disease Most common: Cat scratch disease Toxoplasmosis Syphilis Lyme disease Neuroretinitis & CSD Wear et al. 1983, indicated the causative agent of CSD being Gram –ve Bacilli Sweeney  and Drance.1990 first described Neuroretinitis caused by CSD Regenry et al. 1992, found high antibody titres (>1:64) to Bartonella henselae in 36 of 41 patients with CSD Serologic evidence of CSD in Neuroretinitis 64.3% (Eric Suhler, Ophthalmology vol 107,No5 2000) Ocular manifestations of CSD Parinaud’s oculoglandular syndrome Fever Granulomatous conjunctivitis Regional lymphadenopathy Neuroretinitis Loss of vision. 6/9 to PL Disc swelling Macular star Focal infarct Often unilateral, but can be bilateral Ocular manifestations of CSD Optic neuritis/papillitis Uveitic syndromes Vitritis Acute multifocal inner retinitis,or retinal white dot syndrome Retinitis Choroiditis Ocular manifestations of CSD Retinovascular syndromes BRVO,BRAO Retinal vasculitis Peripapillary angiomatosis Others. Vf defects, ocular motor palsy Ocular features of AIDS-associated CSD Bacillary angiomatosis in conj & retina Pathogenesis & Pathology Pathogen: B. henselae Pathogenesis still unclear, but both neural and retinal tissues are involved.retinal findings Hx. NFL infarcts. Macular star ONH is the principal target in acute neuroretintis, leakage on FFA Necrotizing granulomatous lymphadenitis present Diagnosis High index of suspicion Clinical features Age. Children & adolescents account for majority cases Systemic.regional lymphadenopathy.skin lesion Ocular.macular star,disc swelling Serological IFA(indirect fluorescein assay) of B. henselae ELISAs (enzyme linked immunoassays) IgG & IgM: cut off value > 900 (IgG) ;>250(IgM). F T Kerkhoff, BJO 1999;83:270-275 Lab variation exists. Differentials of Macular star Vascular : AION,BRVO,CRVO,diabetic maculopathy,HT Papilloedema Optic nerve head tumor or infiltrate LISN Treatment Patient education and observation Patient generally well Spontaneous recovery of vision in most of patients No evidence of visual recovery from proposed antibiotics Rx. Side effects from the drugs. Treatment Antibiotics: doxcycline,rifampin,erythromycin,ciprofloxacin, promote resolution of CSD neuroretinitis. Lack of controlled trial. Clear evidence of benefit from Rx  in immunocompromised host.
顶部