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JAMA Ophthalmology Clinical Challenge
July 2014

Transient Blurred Vision in a Neurologically Decompensating Patient

Author Affiliations
  • 1Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St Louis, Missouri
JAMA Ophthalmol. 2014;132(7):887-888. doi:10.1001/jamaophthalmol.2014.631

A healthy woman in her 50s presented to the emergency department with a severe headache for 2 days. Head computed tomography findings were negative and the following day, the headache subsided. Soon thereafter, she was noted to be more forgetful and unsteady. She was seen by an otolaryngologist for left-sided hearing loss and diagnosed as having Meniere disease. Symptoms mildly abated with meclizine hydrochloride and a brief course of steroids. After treatment, she continued to decline neurologically. Subsequently, brain magnetic resonance image findings showed numerous foci of enhancement throughout the brain (Figure 1). She was subsequently admitted to the hospital. Cerebrospinal fluid analysis results were normal except for mildly elevated protein (108 mg/dL). Findings from cerebrospinal fluid Gram stain and cultures were negative. No oligoclonal bands were found. Test results for human immunodeficiency virus, syphilis, enterovirus, West Nile virus, herpes simplex virus types 1 and 2, hepatitis, Cryptococcus, Lyme disease, Rickettsia, and Ehrlichia were negative. Erythrocyte sedimentation rate and C-reactive protein findings were normal. Results from antinuclear antibody, extractable nuclear antigen, rheumatoid factor, and antineutrophil cytoplasmic antibody tests were negative. Chest x-ray showed no hilar adenopathy. She was treated for aseptic meningitis but continued to decline. Ophthalmology was consulted to evaluate the patient when she began to experience transiently blurred vision. On examination, the patient had visual acuity of 20/20 OU. Pupils, intraocular pressure, motility, and confrontational visual fields were normal. External and anterior segment examinations were unremarkable. Dilated fundus examination findings were unremarkable.

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