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Case 26-2010 — A 54-Year-Old Man with Loss of Vision and a Rash
Dr. Joseph D. Tucker (Infectious Diseases): A 54-year-old man was admitted to this hospital because of acute unilateral loss of vision.

On the morning before admission, the patient noted decreased central vision in his left eye. That evening after work, he went to an ophthalmologist. He reported thatperipheral vision in the left eye and vision in the right eye were normal; he did not have headache, eye or neck pain, flashes of light, or other visual symptoms. On examination, visual acuity in the left eye was 20/400. Funduscopic examination of the left eye after dilatation revealed a pale, edematous optic nerve, with fine vessels on the surface, and flame-shaped hemorrhages inferior to the nerve. Theerythrocyte sedimentation rate was reportedly elevated. He was referred to a neurologist, who sent him to the emergency department at this hospital, where he arrived approximately 31 hours after the onset of symptoms.
A diagnosis of stage IIB Hodgkin's lymphoma had been made 10 months before this admission; the presenting symptoms were cervical and mediastinal lymphadenopathy, drenching nightsweats, and pruritus. Treatment included chemotherapy (doxorubicin, bleomycin, vinblastine, and dacarbazine followed by mechlorethamine, procarbazine, and prednisone), which was completed 4 months before admission, followed by radiation therapy (a total of 21 Gy in 12 fractions to cervical and mediastinal lymph nodes), which was completed 1 month before admission. Symptoms resolved after the firstcycle of chemotherapy, and repeat imaging studies at the completion of chemotherapy showed resolution of the lymphadenopathy. Chemotherapy was complicated by persistent pancytopenia and recurrent infections (which persisted after completion of chemotherapy), for which transfusions, growth factors, and antibiotics were administered, and peripheral neuropathy, with numbness and paresthesias in thehands and feet and decreased sensation of pinprick and vibration on examination.
Five months before admission, a macular rash developed on the trunk, associated with low-grade fevers, thought to represent filgrastim-associated neutrophilic dermatitis. Two months before admission, two episodes of vertigo occurred, associated with nausea, vomiting, and unsteady gait. Meclizine was administered, withpartial improvement but some persistent unsteadiness. The patient had lost 20 kg since the diagnosis of lymphoma.
A diagnosis of the Guillain–Barré syndrome had been made 10 years earlier; it was manifested by progressive sensory loss and diminished reflexes, without weakness. Testing for the human immunodeficiency virus (HIV) was negative at that time. Immune globulin was administeredintravenously, and the symptoms resolved within 6 months. The patient also had chronic back pain, with compression fractures of the 11th and 12th thoracic vertebrae and cervical degenerative disk disease. He had had an appendectomy, shoulder arthroscopy, and a fractured leg in the past. Medications on admission included citalopram, lorazepam, antiinflammatory medications, and meclizine. He lived in NewEngland, was married, was monogamous with his wife, and worked in an office. He drank alcohol occasionally, had stopped smoking years earlier, and did not use illicit drugs. His father had cardiovascular disease, diabetes mellitus, and stroke; his mother had arthritis; and his siblings were healthy.

On examination, the temperature was 36.3°C, the blood pressure 90/55 mm Hg, the pulse 71 beats perminute, the respiratory rate 20 breaths per minute, and the oxygen saturation 100% while the patient was breathing ambient air. There was no pain in the scalp or over temporal areas. Corrected visual acuity was 20/20 in the right eye and 20/200 in the left eye, with effort and eccentric fixation. Visual-field testing revealed a dense central scotoma and diminished color vision. The pupils...
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