Clinical case report

What’s the diagnosis?

A previously healthy 8-year-old male presents with complaints of blurry vision and headaches for two weeks. He describes the headaches as generalized with no focal component. Headaches seem worse after school and there is associated photophobia. The patient rates the headache intensity as 7 of 10; intensity lessens with acetaminophen.

There is no history of vomiting or documented fever. He complains of a dry cough, which was thought to be secondary to his seasonal allergies. He notes blurry vision, which is localized to his right eye. The patient does not wear glasses and has had no trauma or evidence of ocular disease such as conjunctivitis.

The family history is positive for diabetes and heart disease. There is a dog, cat and bearded dragon in the home. There has been no recent travel. The remainder of the history is noncontributory.

Figure 1 courtesy of Pediatric Ophthalmology, Prisma Health–Midlands

On physical examination, the patient appears healthy and in no distress. Vital signs are stable. His neck is supple, lungs clear and heart without murmur. There is no hepatosplenomegaly or lymphadenopathy. His neuro exam is nonfocal. Reflexes are normal as is his gait and motor function.

His eye exam reveals decreased acuity on the right. Pupils are equal and reactive to light; extraocular movements are normal. A detailed ophthalmologic exam is performed, which shows a blurry optic disc on the right, optic nerve swelling and macular exudates in a star pattern, all compatible with a diagnosis of neuro-retinitis. (Figure 1)

A CBC and CMP were normal. Further work-up on the patient included Borrelia burgdorferi and Treponema antibody titers, which were negative. An MRI of the orbits revealed mild extra-axial CSF prominence surrounding the right optic nerve with no abnormal enhancement.

Have you figured out the diagnosis?

See Page 11 for the answer.

Article authors

Jonathan Markowitz, MD, FAAP

James Stallworth, MD, FAAP, FAAP