Clinicopathological conference: A case of more than a sprained ankle.

Abstract

A 35-year-old African American woman presented to the emergency department (ED) with the chief complaint of pain in the right ankle after falling down several steps. Upon further questioning, the patient admitted that she had fallen down the stairs because she had had trouble seeing them. She described complete vision loss in the left eye for four days before ED arrival after painless, progressive blurring of two weeks’ duration. Additionally, while in the ED, she began to complain of headache and right eye pain, with blurring of vision. Before the onset of these new visual symptoms, she had never had any ophthalmologic ailments. Review of systems was significant only for chronic sinus congestion and frequent epistaxsis over the prior one to two months. Her past medical history included pregnancy-induced hypertension and an allergy to amoxicillin. She was not taking any medications and did not abuse tobacco, illicit drugs, or alcohol. Physical examination showed normal vital signs and in general, a well appearing woman who was complaining only of ankle pain and swelling. Thorough examination of her head, ears, nose, and throat showed a normocephalic/atraumatic head and an otherwise normal examination. The ocular examination showed intact extraocular muscles, an afferent pupillary defect of the left eye, and no light perception with the left eye. The right eye had a reactive pupil and a visual acuity of 20/40. Slit lamp examination result was normal bilaterally. The fundoscopic examination showed blurred disc margins bilaterally, consistent with papilledema. Examination of the neck, heart, lungs, and abdomen was normal. Extremity examination showed edema and tenderness over the right lateral malleolus, without ecchymosis or bony deformity. Ambulation was possible with the assistance of a cane but was limited secondary to pain. Routine laboratory analysis included a complete blood count and chemistry profile, rapid plasma reagin (RPR), sedimentation rate, angiotensin converting enzyme (ACE) level, lysozyme, rheumatoid factor, antinuclear antibody, and a Lyme titer. Additionally, the patient had ankle radiographs taken, which were normal; her chest radiograph and head computed tomography (CT) scan are presented for review in Figures 1, 2a, and 2b. Upon review of the head CT scan, medical therapy was immediately started and neurosurgery was consulted. The head of the bed remained elevated. Repeated examinations showed declining visual acuity of the patient’s right eye. Routine laboratory results were normal, except for an elevated sedimentation rate (ESR) of 34. The patient was transferred to a tertiary care center for further evaluation and treatment.