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JAMA Ophthalmology Clinical Challenge
September 2018

Abnormal Ophthalmic Examination Results and Elevated Intracranial Pressure

Author Affiliations
  • 1Internal Medicine Department, Scripps Mercy Hospital, San Diego, California
  • 2Ophthalmology Department, Scripps Mercy Hospital, San Diego, California
  • 3Infectious Disease Division, Internal Medicine Department, Scripps Mercy Hospital, San Diego, California
JAMA Ophthalmol. 2018;136(9):1068-1069. doi:10.1001/jamaophthalmol.2018.0085

A white man in his early 30s was referred to our hospital after abnormal findings on a routine ophthalmologic examination. He had traveled from Gabon to the United States 2 weeks earlier. He had no significant medical history except use of correctional lens due to myopia; his body mass index was normal. He had worked in Gabon as an engineer for the past 10 months and reported numerous insect bites, but denied other exposures. He was up to date on required vaccinations and had received doxycycline for the past 10 months for malaria prophylaxis. The patient had no symptoms on presentation and denied fevers, headaches, or visual disturbances. Examination of the fundus showed bilateral elevation of the optic nerve head with blurring of the disc margins (Figure); an ocular ultrasonography showed no optic nerve drusen. A magnetic resonance image of the brain with and without gadolinium was normal, and a magnetic resonance venogram showed no evidence of venous sinus thrombosis. A lumbar puncture demonstrated elevated intracranial pressure (ICP) of 35 mm Hg; white cells, 1/μL (to convert to ×109/L, multiply by 0.001); protein, 0.02 g/dL (to convert to g/dL, multiply byt 10.0); glucose, 55 mg/dL (to convert to mmol/L, multiply by 0.0555); and a negative gram stain.