Clinical Reasoning: Optic disc swelling in a patient with AIDS

Abstract

Listen

Translate article

A 51-year-old man, known to have AIDS and hepatitis C, presented with a 1-week history of painless blurred vision in the left eye. He denied any symptoms of raised intracranial pressure including headache, pulse-synchronous tinnitus, transient visual obscurations, or diplopia. Two months prior, he developed pain in his lower back radiating into both legs and an associated band-like sensation around his waist. He initiated a course of oxycodone medication, and the pain subsided in 4 weeks. On examination, he was normotensive. Visual acuity was 20/20 in the right eye and 20/150 in the left. There was no relative afferent pupil defect (RAPD). Color vision was normal in the right eye (17/17 Hardy Rand and Rittler HRR pseudoisochromatic plates) and absent in the left eye (0/17 HRR plates). Ophthalmoscopy showed marked bilateral optic disc swelling (figure 1, A and C) and macular edema in the left eye. Visual field testing showed a small inferotemporal scotoma in the right eye, with a larger central scotoma in the left eye. Ocular motility and external ocular examinations were normal. There was subjective decrease in light touch and pinprick sensations up to the midshin level bilaterally. There was no spinal sensory level. Deep tendon reflexes were present throughout with flexor plantar responses. The patient's CD4 count was 189 cells/mm3. Figure 1 Imaging Ophthalmoscopic photographs (A, C) show bilateral elevated optic discs with no evidence of hemorrhage or exudates. Fluorescein angiogram (B, D) shows optic nerve hyperfluorescence bilaterally (arrows) with left stippled hypofluorescent spots representing choroidal leakage with nonfilling infiltrates (D, asterisk). ### Questions for consideration: 1. What is your differential diagnosis at this point? 2. What initial investigations would you order? Bilateral optic disc edema is an alarming sign, particularly in this patient with AIDS. It commonly indicates raised intracranial pressure (ICP) due to a space-occupying lesion, a CNS infection, …