History of Present Illness
Cc : Weight loss over the past 3 months, with onset of floaters OU over the past 6 weeks
A 38-year-old man presents in the emergency department (ED) with blurred vision in the right eye (OD) and floaters in both eyes (OU) over the past 6 weeks. He is an artist who lost 24 pounds over the past 3 months and has complained of chronic watery stools since that time. He has no history of pain, photophobia, or redness in either eye.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/80 | 20/25 |
| Intraocular pressure (IOP) (mm Hg) | 12 | 10 |
| Lids/sclera/conjunctiva | Purplish-red lesion on RLL, 0.5 mm diameter. Otherwise, within normal limits (WNL) ( Fig. 53.3 ) | Clear. No injection |
| Cornea | Clear with no keratic precipitate (KP) | Clear with no KP |
| Anterior chamber (AC) | No flare or cell | No flare or cell |
| Iris | Round pupil without posterior synechiae | Round pupil without posterior synechiae |
| Lens | Clear | Clear |
| Vitreous cavity | 0.5 vitreous cell | 0.5 vitreous cell |
| Retina/optic nerve | Swollen optic nerve head with peripapillary hemorrhage, vascular sheathing along arcades and macular edema ( Fig. 53.1 ) | Central retinal granular opacities in atrophic retina surrounded by active border of retinitis in the peripheral retina progressing posteriorly ( Fig. 53.2 ) |
Questions to Ask
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Were you evaluated for your weight loss and watery stools? If so, what tests were done?
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Have you participated in the use of intravenous (IV) drugs or unprotected sex with men or women?
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Have you had any skin lesions on your face or body that have not regressed?
He was recently hospitalized in a community hospital for weight loss and frequent diarrhea. A colon biopsy was done, and he was told that he had an infection with a fungus, cryptococcosis, and was started on IV therapy with amphotericin and another drug. He was then sent to the ED. He has had unprotected sex with men, and he has had a little red nodule on the right lower lid for the past few months ( Fig. 53.3 ).
Assessment
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Infectious retinitis, OU, presumably secondary to immune suppression
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Cryptococcosis enteritis
Differential Diagnosis
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Cytomegalovirus (CMV) retinitis secondary to acquired immunodeficiency syndrome (AIDS)
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Human immunodeficiency virus (HIV) retinopathy
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Causes of infectious retinitis (syphilis, herpes simplex virus [HSV], varicella zoster virus [VZV])
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Toxoplasma retinochoroiditis
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Fungal retinitis (e.g., Candida )
Working Diagnosis
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CMV retinitis and Kaposi sarcoma secondary to AIDS
Testing
