A 56‐Year‐Old Man With Visual Changes and Arthralgias

Abstract

A 56-year-old white male presented with several months of visual changes and diffuse myalgias. He reported difficulty seeing out of the lower portion of his left eye for several months, which he described as "cigarette smoke clouding [his] vision." He also reported mild discomfort with movement of the affected eye. He attributed the visual loss to potential injury during his work as a welder. In addition, he complained of several months of diffuse body pain and stiffness and generalized malaise. The pain and stiffness were worse in his shoulders and hips and were worse in the morning, with improvement by the middle of the day. On some days, these symptoms were so severe that he was unable to go to work. He also noted a vague bitemporal headache, worse on the left than the right. Past medical historyHis past medical history was notable for recently diagnosed type 2 diabetes mellitus, for which he was prescribed metformin. Social and family historyHe was born in the US and had spent the majority of his life in San Francisco. He worked as a manager and welder in an automobile repair shop. He lived alone and was sexually active with multiple female partners. He abused methamphetamines. He denied alcohol or tobacco use. His family history was unremarkable. Review of systemsHe had no fevers or night sweats and his weight was stable. He had no scalp tenderness or jaw or tongue claudication. He had no eye redness. He had no chest pain, dyspnea, or cough. He denied any rashes. Physical examinationHe was afebrile with an oral temperature of 37.1°C. His blood pressure was 126/76 mm Hg, his pulse was 87 beats per minute, his respiratory rate was 16 breaths per minute, and his room air oxygen saturation was 100%. His conjunctivae were not injected and anicteric. His extraocular movements were intact. His visual acuity was 20/20 on the right and 20/25 on the left. He had a sluggish left pupillary reflex and 30% red desaturation of the left eye. He had an inferior field defect on the left. On funduscopic examination he had left optic disc swelling. Photographs of his funduscopic examination are shown in Figures 1 and 2. His temporal arteries were pulsatile and nontender. His neck was supple, and he had no meningeal signs. His cardiac examination was regular with no murmurs, rubs, or gallops. His carotid, brachial, radial, and femoral pulses were 2+. His lungs were clear to auscultation. His abdomen was soft and without organomegaly. He had no synovitis or joint effusions and had full range of motion in all of his joints. He had no palpable cervical, axillary, or inguinal lymph nodes.