Headache, red eyes, blurred vision and hearing loss

Abstract

A previously healthy 48-year-old Chinese woman presented with a one-week history of redness, blurred vision and discomfort in both eyes. She also had a frontal headache, and tinnitus and hearing loss in both ears. There was no history of head injury.The patient was alert and oriented. She had nuchal rigidity and a low-grade fever (temperature 37.6°C). Examination of the cranial nerves gave normal results, and there were no cerebellar or long tract motor or sensory signs. There was no rash or lymphadenopathy.The patient's visual acuity, according to a Snellen chart, was 20/30 in each eye. Both pupils had normal direct and consensual light reflexes; visual field, colour vision and the intraocular pressure in each eye were within normal limits. Slit-lamp biomicroscopy of the anterior ocular segment showed mild conjunctival injection and anterior uveitis without hypopyon. Proptosis and orbital bruit were absent. There were no external changes in the ears, and the tympanic membranes in both ears were normal.A complete blood count and erythrocyte sedimentation rate were within normal limits. Lumbar puncture showed clear cerebrospinal fluid and an opening pressure of 16 (normal 10-20) cm water. Analysis of the cerebrospinal fluid showed 185 leukocytes/mm 3 (100% lymphocytes), a protein concentration of 0.2 (normal 0.1-0.5) g/L and a glucose level of 4.0 (normal 2.2-4.2) mmol/L. No micro-organisms were identified in a Gram stain and fungal smear. Magnetic resonance imaging of the head without contrast showed no abnormalities. What is the next step?Which of the following would be the least appropriate next step? a. Administer broad-spectrum intravenous antibiotics without delay. b. Administer systemic steroids. c. Refer the patient to an ophthalmologist for fundal fluorescein angiography. d. Refer the patient to an otolaryngologist for audiometry.The answer is (b). Systemic steroids should not be administered before an underlying infection, which could be the cause of this clinical presentation, has been excluded. In a patient with clinical and laboratory features of meningitis, it is important to administer empirical broad-spectrum antibiotics until cerebrospinal microbial cultures return negative results or when clinical judgement supports discontinuing therapy. This patient had clinical features of lymphocytic meningitis and anterior and posterior uveitis, which suggested a uveomeningeal syndrome.The causes of uveomeningeal syndromes include autoimmune, infectious and neoplastic disorders; therefore, a thorough investigative work-up should be done before systemic steroids are given.An ophthalmologic evaluation -including stereoscopic examination of the fundus and fundal fluorescein angiography -can help determine the intraocular extent of uveitic involvement and identify the diagnostic fundal and angiographic markers of some syndromes with uveitis. Early assessment of the type, extent and severity of uveitis by an ophthalmologist is important to ensure timely treatment and prevent adverse effects. Although an otolaryn...

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