History of Present Illness
A 60-year-old man with a history of prediabetes presents to the emergency department with 2 days of increasing floaters and blurry vision in both eyes, as well as 4 days of malaise, body aches, and chills. He denied fevers, neck stiffness, dysarthria, or focal weakness. Two days before presentation, his primary care physician prescribed oral doxycycline for a presumed tick-borne illness, but the patient’s symptoms continued to worsen.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/100 | 20/100 |
| Intraocular pressure (IOP) | 13 | 13 |
| Sclera/conjunctiva | White and quiet | White and quiet |
| Cornea | Clear | Clear |
| Anterior chamber (AC) | 2+ white cells | 2+ white cells |
| Iris | Unremarkable | Unremarkable |
| Lens | Clear | Clear |
| Anterior vitreous | 2+ cells | 2+ cells |
| Dilated fundus examination (DFE) | See Fig. 67.1A | See Fig. 67.1B |
Questions to Ask
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Have you had recent exposure to mosquitoes?
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Have you traveled abroad recently?
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Do you engage in unsafe sex practices?
He reported recent exposure to mosquitoes. He denied recent travel or participation in unsafe sex practices.
Assessment
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Bilateral acute nongranulomatous panuveitis with chorioretinal lesions
Differential Diagnosis
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West Nile virus (WNV)–associated panuveitis
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Less likely: tuberculosis-, syphilis-, or sarcoid-associated panuveitis or lymphoma
Working Diagnosis
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WNV-associated panuveitis
Testing
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Serology (immunoglobulin M [IgM] and immunoglobulin G [IgG] WNV antibodies) should be obtained from blood to confirm the diagnosis. Polymerase chain reaction (PCR) testing from blood is less likely to yield a positive result after the first week of illness. In cases with mental status changes, headache, and/or stiff neck, serology and PCR testing can be performed on cerebrospinal fluid (CSF).
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Fluorescein angiography highlights the “target” lesions with hypofluorescent centers and hyperfluorescent edges, which may be challenging to visualize on examination ( Fig. 67.2 ).
