A 37-year-old man reported waking up and noticing a black spot in his vision in his left eye 2 days prior to presentation. He reported that the spot lasted 12 hours and then dissipated. For two weeks prior to this episode, the patient noted intermittent “shimmering” lights in both eyes. The patient now reports having difficulty with vision in his upper visual fields in both eyes.
The patient’s past medical history is significant for an episode of malaise and myalgias after his young daughter had gastroenteritis six months prior to his ocular complaints. His symptoms were followed by severe headaches and an acute episode of confusion and altered mental status. He was seen at an outside hospital and an MRI of the brain showed numerous white matter lesions, including lesions in the corpus callosum. He had mild pleocytosis of his cerebrospinal fluid (CSF). He was felt to have a postinfectious encephalopathy versus demyelinating disease and was treated with methylprednisolone. His cognitive symptoms improved significantly and there was some resolution of the white matter lesions on repeat MRI with no further treatment. He continued to complain of some mild residual fatigue which prevented him from working. Six months after his initial symptoms, he was re-admitted to the hospital for another episode of confusion and headache. There was no history of skin lesions. There were increased white matter lesions on MRI. Cerebrospinal fluid demonstrated elevated protein but a normal white blood cell count. An angiogram and a right frontal brain and leptomeningeal biopsy of one of the lesions were unrevealing. An extensive laboratory panel was negative. The patient’s symptoms improved with methylprednisolone, but he continued to have confusion and headaches on oral prednisone. The patient also began to complain of hearing loss.
The patient then began to have ocular complaints and ophthalmologic evaluation was performed serially.