History of present illness
A 45-year-old woman with a past medical history of chronic alcoholism, gastric bypass surgery, and multiple psychiatric conditions noted painless decreased vision in the right eye approximately 1.5 weeks earlier, which had remained stable since initial decrease in vision. She had no previous ocular history, though she noted that she may have had a lazy eye as a child. Review of systems was unremarkable.
Ocular examination findings
Visual acuity without correction was hand motions in the right eye and 20/20 in the left eye. Both pupils were round and reactive to light, and there was no afferent pupillary defect. Color plates could not be assessed in the right eye because of the degree of vision loss and were full in the left eye. Confrontational visual fields were constricted in the right eye and full in the left. Anterior segment examination was unremarkable except for trace nuclear sclerosis. Dilated fundus examination was notable for a placoid, well-circumscribed yellow-white lesion involving the macula of the right eye.
Questions to ask
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Does the patient have a history of sexually transmitted infection(s) or multiple sexual partners?
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She has had multiple sexual partners.
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Is there a history of HIV and/or immunosuppression?
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None known; HIV test ordered
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Does the patient have an autoimmune disease?
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No
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Is there a history of systemic malignancy?
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No
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Has the patient had any recent exposure to an infectious disease?
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None that she can recall
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Has the patient had any recent flu-like illness?
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Patient denies any symptoms.
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Assessment
This is a case of a 45-year-old woman with a past medical history of chronic alcoholism, gastric bypass surgery, and multiple psychiatric conditions who presents with decreased vision in the right eye, examination and imaging notable for a placoid chorioretinitis in the right eye, and multiple punctate areas of chorioretinitis in the periphery of both eyes.
Differential diagnosis
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Acute syphilitic posterior placoid chorioretinitis
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Early acute zonal occult outer retinopathy
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Sarcoidosis
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Tuberculous choroidopathy
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Metastases
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Acute posterior multifocal placoid pigment epitheliopathy
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Serpiginous choroidopathy
Working diagnosis
Acute syphilitic posterior placoid chorioretinitis
Multimodal testing and results
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Widefield fundus imaging
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Our patient’s imaging demonstrated a yellow-white placoid lesion in the posterior pole with multiple subtle punctate white lesions in the periphery of both eyes.
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A wide range of inflammatory changes in the retina can also be present, including phlebitis, retinitis, retinal infiltrates, vitritis, optic neuritis, and/or atrophy.
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Fluorescein angiography
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Our patient’s imaging demonstrates early hypofluorescence and late staining of the placoid lesion in the right eye without any areas of hypofluorescence or staining noted in the left eye.
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Fundus autofluorescence
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Our patient’s imaging demonstrated a well-circumscribed area of hyperautofluorescence corresponding to the yellow-white placoid lesion with adjacent irregular mottling in the right eye ( Figs. 36.1 and 36.2 ). The periphery of both eyes demonstrated multiple punctate hyperautofluorescent lesions in a 360-degree distribution.
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