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.
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