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CASE PRESENTATION. « Doctor my pupils are dilated » Richard Plantive R3 Emergency Medicine November 17, 2004. CASE PRESENTATION. ID: 41 year old female PMHx: renal cysts Meds: none. CASE PRESENTATION. HPI Blurry vision Near vision more blurry than far

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case presentation

CASE PRESENTATION

« Doctor my pupils are dilated »

Richard Plantive

R3 Emergency Medicine

November 17, 2004

case presentation2
CASE PRESENTATION

ID: 41 year old female

PMHx: renal cysts

Meds: none

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CASE PRESENTATION
  • HPI
    • Blurry vision
    • Near vision more blurry than far
    • Intermittent, lasts hours at a time
case presentation4
CASE PRESENTATION
  • HPI
    • 4 d ago noted right pupil larger than left
    • Today noted same, but more pronounced
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CASE PRESENTATION
  • HPI
    • No diplopia
    • No headache
    • No occular pain
    • No bulbar symptoms
    • No weakness
    • No numbness
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CASE PRESENTATION
  • ROS
    • Transient left 4th & 5th finger numbness four months ago
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CASE PRESENTATION
  • O/E
    • Vital signs wnl, afebrile
  • H/N
    • Pupils
      • Right: 9mm – 9mm
      • Left: 8mm – 7.5mm
      • No accomodation
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CASE PRESENTATION
  • H/N
    • EOMI
    • Normal saccades
    • No nystagmus
    • Conjugate gaze
    • No ptosis
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CASE PRESENTATION
  • CNS
    • Mental status: normal
    • CN (IV – XII): normal
    • Motor: normal
    • Reflexes: 2+ , downgoing plantars
    • Sensory: normal (touch, position, vibration)
    • Coordination: normal
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CASE PRESENTATION
  • DDx
    • Adie`s pupil
    • CN III lesion
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CASE PRESENTATION
  • Imaging
    • CT head: nil acute
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CASE PRESENTATION
  • Imaging
    • CT angiography
      • No evidence of aneurysm in the anterior or posterior circulations. No vascular malformations. A developmental venous anomaly (DVA) of the left cerebral hemisphere is noted and is of no clinical significance.
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CASE PRESENTATION
  • Efferent Pupillary Defect DDx
    • A
    • B
    • C
    • D
    • D
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CASE PRESENTATION
  • Efferent Pupillary Defect DDx
    • Adie’s pupil
    • Botulism
    • CN III lesion
    • Direct trauma
    • Drugs
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CASE PRESENTATION
  • Adie’s pupil
    • c/o anisocoria, blurred vision esp. near
    • Accomodative defect
    • ½ have areflexia of lower limbs
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CASE PRESENTATION
  • Adie’s pupil
    • Defect at level of ciliary ganglion or short ciliary nerve
    • Idiopathic
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CASE PRESENTATION
  • Botulism
    • Botulinum toxin binds irreversibly to ________ neuron
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CASE PRESENTATION
  • Botulism
    • Botulinum toxin binds irreversibly to presynaptic neuron
    • Peripheral & cranial nerves
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CASE PRESENTATION
  • Botulism
    • Clostridium botulinum
      • Anaerobic Gram positive rod
    • Produces an exotoxin
    • Toxin internalized into presynaptic neuron, inhibiting ACh release
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CASE PRESENTATION
  • H & P
    • Occular signs
      • Ptosis
      • Extraoccular palsies
      • Markedly fixed & dilated pupils
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CASE PRESENTATION
  • H & P
    • Occular symptoms
      • Diplopia
      • Blurred vision
      • Photophobia
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CASE PRESENTATION
  • CN III lesion
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CASE PRESENTATION
  • CN III lesion
    • Vascular lesion
    • Aneurysm
    • Neoplasm
    • Trauma – transtentorial herniation
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CASE PRESENTATION
  • CN III lesion
    • Inflammatory
    • Infiltrative lesion
    • Cavernous sinus lesion
    • Ophthalmoplegic migraine
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CASE PRESENTATION
  • Direct trauma
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CASE PRESENTATION
  • Direct trauma
    • Damage to the nerve endings
    • Damage to the iris sphincter muscle
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CASE PRESENTATION
  • Drugs
    • Anticholinergics
    • Prototypical anti-Ch belladonna alkaloids
      • Atropine, scopolamine, hyoscyamine
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CASE PRESENTATION
  • Drugs
    • Muscarinic ACh receptors (central & peripheral)
      • Smooth muscle of the eye, intestinal tract, urinary bladder
      • Sweat, salivary, mucosal gland activity
      • CNS – new information storage, general perception, cognitive modalities, motor coordination
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CASE PRESENTATION
  • What is the patient’s diagnosis?
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CASE PRESENTATION
  • Brugmansia
    • Family Solinaceae
      • Atropa belladonna
      • Mandragora officinarium
      • Datura spp.
      • Brugmansia spp.
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CASE PRESENTATION

Emergency Medicine(2003) 15, 376-382

Isbister, Oakley, Dawson, Whyte

Presumed Angel’s trumpet poisoning: Clinical effects and epidemiology

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CASE PRESENTATION
  • June 1990 – June 2000
  • 33 patients
  • 31 recreational ingestion
  • 2 deliberate self-poisoning
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CASE PRESENTATION
  • Summary
    • Efferent pupillary defect
    • DDx: A, B, C, D, D
    • Anatomy & physiology & pathology
    • Brugmansia