Unexplained Fever in Pregnancy
Dr. Rathinam Sivakumar Uveitis Services Consultant, Uveitis Service Aravind Eye Hospital Madurai India General History 26 year old lady, engineer sudden painless loss of
vision in BE since 3days fever and cough for two months cough was associated with haemoptysis amenorrheaof 3 months,hospitalizedand treatedwithATT at general gynecology department. Then referred to our hospital EXAMINATION VA DISTANCE NEAR 3/60 NIG or PH N36 at 25cm 3/60 NIG or PH
ANTERIOR SEGMENT CORNEA CLEAR ANT.CHAMBER ND ,QUIET IRIS NCP PUPIL REACTION ILLSUSTAINED LENS EOM FULL EXAMINATION BE MEDIA CLEAR; NO VIT HAZE DISC DISC ODEMA VESSELS SHEATHING OF VESSELS;ACTIVE VASCULITIS MACULA DULLFR BACKGROUND RETINA MULTIPLE COTTON WOOL SPOTS; MULTIPLE SPLINTER HAGE Initial Diagnosis of Ocular Disease
Retinal vascular occlusive disease of unknown origin Investigations Hb: 7g% WBC: 8,600 cells/cumm, platelets: 2 lakhs/cumm
ESR: 28mm at hr, 55mm at 1 hr Bleeding & Clotting Time : Normal CRP: 22.9mg/ lit (N: up to 6 mg/l) serum amylase: 91 IU/L (0 to 85 IU/L) serum rheumatoid factor: 3.14 IU/ml (0 to 30) plasma fibrinogen: 182 mg% BL.glucose; sr creatinine; blood urea: WNL PS: MICROCYTIC HYPOCHROMIC ANEMIA; NEGATIVE FOR MALARIAL PARASITE urine analysis: trace albumin Differential Diagnosis
Adamantiades Behcets Disease Polyarteriitis nodosa Takayasu disease Wegeners granulomatosis syphilis systemic lupus erythematosus History Review h/o hair loss h/o malar rash occasional joint pains
no h/o oral or genital ulcers no h/o headache no h/o DM or HTNin self or family Diagnosis SLE Retinopathy Immediate Treatment intravitreal triamcinolone acetate0.1ml was given in BE as a firstpossible ocular treatment as the patient was pregnant, she wasreferred to the Rheumatologist forsystemic treatment Investigation Rheumatologist for further invest.:
ANA: 9.2mg% (0.9 to 1.4mg%) Anti Ds DNA; C3, C4; positive Renal Function Test : WNL Liver Function Test : WNL Therapy all drugs have to be safe in pregnancy prednisolone 40 mg
ecosprin 75mg calcium supplement blood transfusion 1 pint Counseled for medical termination ofpregnancy. Therapy Follow-up medical termination of pregnancy was carried out.
IV cyclophosphamide first cycle pulse methylprednisolone 1gm 3 days andmaintained of oral prednisolone 1mg/kg body wt. Persistent vasculitis and progressive cotton wool spots
Follow up After 1 Week BE disc pallor and macularodema Follow-up After 1 Month
OD no glaucomatous discdamage OU resolved macular edema no active vasculitis Follow-up After 1 Month
RE LE Vision DISTANCE NEAR 2/60 6/60PH6/18P (Untreated with TCA) N 12at 33 cm IOP (mm Hg) 30 12 Therapy Revision for OD
Mycophenolate mofetil 1500mg/day Prednisolone 20mg /day Brimonidine 0.2% and Timoptol 0.5% Patient shifted her residence and got lost for follow up for 6 months Follow-up After 6 months
OD Extensive vascular occlusion resolved macular edema Advised FFA SEVERE VASCULAR OCCLUSION WITH
MACULAR ISCHEMIA NVD on the optic disc Therapy updated PRPin 3 sitings for the OS after discussion withrheumatologists: Trental as vasodilatator 400mgBD 15 days Follow-up After 7 months
presented with sudden onsetdefective vision since twodays in OS Follow-up Ocular Examination
VISION /60 HAND MOVEMENTS CORNEA CLEAR AC SHALLOW ND PUPIL 5mm FIXED 3mm SLUGGISH lRIS ECTROPION UVEA; NVI;PAS NCP LENS PSCC IOP 42 12 FUNDUS CDR:0.8, inf NRR thinning NVE; Media hazy DISPERSED VH FOLLOW UP ON JUNE,14TH 2010 Ocular Examination pale optic disc sclerosed vessels CWS
premacular hemorrhage Pars PlanaVitrectomy with C3F8 under GVP Treatment PPV+C3F8 under guardedvisual prognosis Follow-up After 8 months
RE LE VISION 1/60 6/12 IOP (mmHg) 36 15 Treatment was continued with immummunosuppressives and topical Dorzolamide 2% for the OD Follow-up After 9 months
RE LE VISION 1/60 6/9p IOP(mm Hg) 18 10 Treatment diode cyclophotocoagulation in OD vitreous lavage in OS she failed to follow-up. Discussion autoimmune, non-organ specific connective tissue disorder
20% have ocular involvement 90% are women, mostly of child bearing age all age groups and both genders affected ocular activity may occur independent of systemic activity Lupus retinopathy is an imp marker of disease activity ocular inflammatory lesions may precede extraocular manifestation by several months Conclusion Although ocular involvement is benign,potentially blinding complications may occur. Lupus retinopathy and neuro-ophthalmicinvolvementsuggestsystemic activity,therefore referral to a RHEUMATOLOGISTfor management is mandatory. Early diagnosis and timely institution ofsystemic therapy may minimize morbidity andmortality.