An interesting case of Vision loss

S. KarthikeyanProf. P. Vijayaraghavan’s Unit

M5Special Thanks: Prof K.S. Chenthil.,IMCU

On 18/9/10

30yr male Mr. Srinivasan,admitted in surgery dept.

c/o pain abdomen 2 days Diagnosed and treated as Acute pancreatitisImaging and biochemical analysis supportingDeveloped AKI – 3 cycles of HD doneTransferred to IMCU on 25/9/10

25/9/10 In IMCU loss of vision in rt eye noted -2 d complete painless no reddening/watering drooping of eye lid +No h/o floaters No h/o diplopiaNo h/o traumaNo h/o similar symptoms in other eye

No h/o sugg.of other cranial nerve involvement

No h/o difficulty in using the limbs No h/o disturbance in sensory modalitiesNo h/o involuntary movementsNo h/o headache/ blurring of vision/projectile

vomitingNo h/o altered sensorium

h/o fever -3 days continuous low grade no rigors/chillsh/o abdominal pain+ diffuse/dull aching not radiating no agg./relieving factors intensity over past 3 daysh/o abdominal distension+ over past 3 days

h/o vomiting -7 days back 5-6 episodes/d non-bilious lasting for 2 days h/o constipation- 5 days h/o passing flatus+ No h/o passing bulky stools No h/o hematemesis/bleeding PR/melena No h/o jaundice No h/o cough/ shortness of breath No h/o polyuria/polyphagia No h/o nasal/ear discharge No h/o leg swelling/facial puffiness h/o loss of appetite+ No h/o loss of weight

Past h/o: no similar episodes not a known HT/DM/ BA/PTBPersonal h/o: smoker 2 yrs alcoholic 7 yrs mixed dietFamily h/o: no similar illness in family

GE: conscious/oriented

Febrile temp-101F

no pallor/icterus/cyanosis/clubbing/ pedal edema JVP /hydration fair/no lymphadenopathy

R –Eye : Ptosis+ /no reddening/no tenderness/no proptosis L—Eye : Normal

VITALS: Pulse 105/min B.P 110/70 mmHg

CVS: S1S2+ No murmur

RS: NVBS

Abdomen: soft, non tender, no shifting dullness BS+/sluggish

CNS: HMF: Conscious oriented speech- Normal Memory-Intact GCS: 15/15 Pupils:

RIGHT LEFT

5mm—Dilated , not reacting to light

2mm—Reacting to light

CRANIAL NERVES:

NO: RIGHT LEFT

1 N N

2 No PR/PL N

3,4,6 Palsy N

5 N N

7,8 N N

9,10,11,12 N N

MOTOR SYSTEM: NADSENSORY SYSTEM: NADGAIT & COORDINATION: NormalCFT: NormalSPINE & CRANIUM: Normal No e/o meningeal signs

PROBLEMS: Alcoholic

Pain abdomen

AKI– On HD

Fever

R– 2,3,4,6 cranial nerve involvement

DDs :

Purtscher’s Retinopathy

Cavernous sinus thrombosis

Superior orbital fissure syndrome

Orbital Apex syndrome

Purtscher’s Retinopathy:

rare complication of acute

pancreatitis

occlusion of posterior retinal artery by granulocytes

sudden loss of vision

3,4,6 not involved

CAVERNOUS SINUS THROMBOSIS:

Unilateral 24– 48 hrs bilateral

can occur in pancreatitis due to dehydration

chemosis/redness+

proptosis+

blurring of vision +

sudden vision loss rare

3,4,6 cr.nerves involved

5 cr.nerve involvement characteristic

Superior orbital fissure Syndrome:

3,4,6 cranial nerves involved

2,cranial nerve not involved

Orbital Apex syndrome:

2,3,4,6 cr. nerves involved

5,cr. nerve not involved

Diagnosis : Acute pancreatitis

AKI

Orbital apex syndrome

? Infective etiology—Orbital cellulitis ? Sepsis

Investigations CBC Hb 13.5 g/dl TC 14,500 DC P60 L40 ESR 10/25 Plt 1 Lakh PCV 40

18/9 21/9

25/9 27/9 30/9

12,500 13,OOO 14,500 14,000 13,500

P60 L40 P62 L38 P58 L42 P60 L40 P60 L40

RFT

Intake/output

18/9 20/9 22/9 25/9 27/9 29/9 30/9

UREA 120 180 150 130 100 70 60

CREAT 3.2 5.O 4.5 4.0 3.0 2.0 1.4

18/9 20/9 22/9 25/9 27/9 29/9 30/9

INTAKE 2500 1500 1500 1500 1500 2000 2000

OUTPUT 500 200 500 700 1100 1500 1700

RBS/ Urine ketones:

Sr.ELECTROLYTES:

18/9 20/9 22/9 25/9 27/9 29/9

RBS 450 375 400 300 200 150

URINEKETONES

+ + + + + --

18/9 22/9 25/9 27/9

Na 140 135 138 140

K 4.0 3.5 4.0 4.0

Ca 10 ----- ----- 9.5

LFT:T.Bilurubin– 1.0 mg/dlDirect --- 0.4 mg/dlSGOT--- 90 IU/LSGPT---85 IU/LSAP----100 IU/L

LIPID PROFILE--Normal

Sr .Amylase/Lipase:

ABG: Metabolic Acidosis with compensatory respiratory Alkalosis with anion gap

18/9 20/9 23/9 25/9 27/9

Amylase 1873 1200 500 200 50

Lipase 1100 800 750 500 300

ECG: WNL

CXR—L Sided pleural effusion USG Abdomen 25/9: Pancreas obscured Fatty liver+ ascites + CT Abdomen: Bulky pancreas+

Fever profile:

Smear Mp/Mf :Blood Widal : NegativeMSAT :Dengue IgG/M:

Blood c/s:Urine c/s: Negative Swab from CV catheter:Nasal swab c/s: HIV ELISA: NegativeVDRL:

Ophthal opinion: Gen. Arteriolar narrowing+ Ghost vessels+ Cherry red spot + Disc –temporal pallor + Imp: s/o CRAOENT : Sugg. DNENeuromedicine opinion: ?Orbital apex syndrome Sugg. MRI

R- Maxillary sinusitis with ? # medial wall of maxilla

Hyperglycemia/ketones+/Acidosis

CT--R- Maxillary sinusitis with ? # medial wall of maxilla[ ! EROSION ]

Fundus s/o CRAO [!Vascular invasion] ?MUCORMYCOSIS

Nasal swab for KOH mount: hyphal elements+ sugg.fungal c/sDNE : Nasal crust for HPE

MRI Brain with Orbital cuts:

In posterior part of orbit

T1– Hypointensity +T2—Hyperintensity+

Brain normal

FINAL DIAGNOSIS:

CHRONIC ALCOHOLISMACUTE PANREATITISAKIKETOACIDOSIS RHINO ORBITAL MUCORMYCOSIS

ACUTE PANCREATITIS AND KETO-ACIDOSIS:

Ketonemia/ketonuria usually not a feature of Acute pancreatitis POSSIBLE ASSOCIATIONS:Pre-existing DM with Acute PancreatitisAcute on Chronic Pancreatitis:

DM 2 to chronic pancreatitis ̊�Super imposed on acute episodeCan develop ketoacidosis

Contd…

Alcoholic ketoacidosis with superimposed Acute pancreatitis

“Pancreatic ketoacidosis” Ref: U.M.Kabadi et al Post graduate Journal

of Medicine VA MEDICAL CENTER PHOENIX ARIZONA

“PANCREATIC KETOACIDOSIS”

Acute pancreatitis

Lipase

Peripheral fat breakdown

Ketosis/acidosis

Initial treatment:

NPOInj Meropenam 1g i.v tid

Inj Pantoprazole 40 i.v. bd

Inj Tramadol i.m sos

Inj Paracetamol i.m sos

Fluid management:

IVF ---OUTPUT + 600 mlClear fluids orally after 2 days

Inj Insulin HA 5U/hr in NS

Inj Insulin HA 10U In 500ml DNS maintenance

Inj HA s.c. 5U tds after starting oral

MANAGEMENT:Inj. Inj.Amphotericin B i.v – 1.5mg/kg/d over 8-12 hrs

MUCORMYCOSIS“ZYGOMYCOSIS”Serious, uncommonAggressive, lethally invasive mycosisETIOLOGY: Order--Mucorales Genus--Mucor Rhizopus Rhizomucor Absidia

Pathogenesis: Non-pathogenic/Environmental

Spores inhaled—Airway deposition {normally don’t germinate}

Blood sugar/Acidemia Iron overload

Germinate to hyphae

Blood vessel/neural invasion Tissue necrosis

Clinical manifestations:

Rhino-orbital-Cerebral

Pulmonary

Gastrointestinal

Cutaneous

Rhino-orbital-Cerebral Mucormycosis:

Clinical manifestations:Symptoms of sinusitis+Ocular muscle palsy+Sudden loss of vision-retinal artery

invasionProptosis /ptosisBlack Eschar– Palatal involvementCavernous sinus thrombosisBrain abcess/Phlegmon

Pulmonary mucormycosis:

Neutropenia-predisposing factor

Severe pneumonia

Cavitation develops rapidly

High mortality

Gastrointestinal mucormycosis:Occurs in PEM patients

Presents as Perforated viscus

High mortalityCutaneous mucormycosis:

CommonIn sites of trauma

Self limiting area of tissue necrosis

Lab features:Abnormalties reflect predisposing conditions

MicroscopyBiopsy DIAGNOSTICCulture & Sensitivity

STAINS USED:Gomori-methanamine silver,PAS

Management:Reversal of underlying conditionSurgical debridementAnti fungal therapy:Inj.Amphotericin B i.v – 1.5mg/kg/d, can be

stepped upLIPOSOMAL PREPARATIONS:

AmBisome– 15-20mg/kg/dAbelcet—15mg/kg/d

RECENT ADVANCES:Posaconazole –new triazoleCan be used in amphotericin failure Prophylaxis in immunocompromised

FOLLOW UP:Therapy may be required for 3 months after

Clinical stabilisationLab studies,scans,X-rays yield normal results

Follow upto 1 yr necessary

Carry home points

Ketonemia/ketonuria usually not a feature of Acute Pancreatitis

Pancreatitic ketoacidosis – a rare possibility,still can be considered

Mucormycosis is common on ketoacidosisCan be under-reported as SINUSITISTreatment should be aggressive

References :

Harrison’s Principles of Int.Medicine,17 Edition

Kanski’s text book of ophthalmology

‘eMedicine’

Journal

‘Mucormycosis a complication of critical care’ by William A. Agger, MD; Dennis G. Maki, MD Arch Intern Med. 1978;138(6):925-927 ‘ACUTE PANCREATITIS BY RENAL CORTICAL NECROSIS AND CEREBRAL MUCORMYCOSIS’ by C. L. Aszkanazy Dolman and J. A. Herd *From the Departments of Pathology, Vancouver General Hospital and University of British Columbia

Can Med Assoc J. 1959 October 1; 81(7): 562–564.

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