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CASE PRESENTATION

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CASE PRESENTATION

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  1. CASE PRESENTATION « Doctor my pupils are dilated » Richard Plantive R3 Emergency Medicine November 17, 2004

  2. CASE PRESENTATION ID: 41 year old female PMHx: renal cysts Meds: none

  3. CASE PRESENTATION • HPI • Blurry vision • Near vision more blurry than far • Intermittent, lasts hours at a time

  4. CASE PRESENTATION • HPI • 4 d ago noted right pupil larger than left • Today noted same, but more pronounced

  5. CASE PRESENTATION • HPI • No diplopia • No headache • No occular pain • No bulbar symptoms • No weakness • No numbness

  6. CASE PRESENTATION • ROS • Transient left 4th & 5th finger numbness four months ago

  7. CASE PRESENTATION • Other Hx?

  8. CASE PRESENTATION • O/E • Vital signs wnl, afebrile • H/N • Pupils • Right: 9mm – 9mm • Left: 8mm – 7.5mm • No accomodation

  9. CASE PRESENTATION • H/N • EOMI • Normal saccades • No nystagmus • Conjugate gaze • No ptosis

  10. CASE PRESENTATION • CNS • Mental status: normal • CN (IV – XII): normal • Motor: normal • Reflexes: 2+ , downgoing plantars • Sensory: normal (touch, position, vibration) • Coordination: normal

  11. CASE PRESENTATION • Labs

  12. CASE PRESENTATION • DDx?

  13. CASE PRESENTATION • DDx • Adie`s pupil • CN III lesion • …

  14. CASE PRESENTATION • Imaging?

  15. CASE PRESENTATION • Imaging • CT head: nil acute

  16. 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.

  17. CASE PRESENTATION • Efferent Pupillary Defect DDx • A • B • C • D • D

  18. CASE PRESENTATION • Efferent Pupillary Defect DDx • Adie’s pupil • Botulism • CN III lesion • Direct trauma • Drugs

  19. CASE PRESENTATION • A

  20. CASE PRESENTATION • Adie’s pupil • c/o anisocoria, blurred vision esp. near • Accomodative defect • ½ have areflexia of lower limbs

  21. CASE PRESENTATION • Adie’s pupil • Defect at level of ciliary ganglion or short ciliary nerve • Idiopathic

  22. CASE PRESENTATION • B

  23. CASE PRESENTATION • Botulism • Botulinum toxin binds irreversibly to ________ neuron

  24. CASE PRESENTATION • Botulism • Botulinum toxin binds irreversibly to presynaptic neuron • Peripheral & cranial nerves

  25. CASE PRESENTATION • Botulism • Clostridium botulinum • Anaerobic Gram positive rod • Produces an exotoxin • Toxin internalized into presynaptic neuron, inhibiting ACh release

  26. CASE PRESENTATION • H & P • Occular signs • Ptosis • Extraoccular palsies • Markedly fixed & dilated pupils

  27. CASE PRESENTATION • H & P • Occular symptoms • Diplopia • Blurred vision • Photophobia

  28. CASE PRESENTATION • C

  29. CASE PRESENTATION • CN III lesion

  30. CASE PRESENTATION • CN III lesion • Vascular lesion • Aneurysm • Neoplasm • Trauma – transtentorial herniation

  31. CASE PRESENTATION • CN III lesion • Inflammatory • Infiltrative lesion • Cavernous sinus lesion • Ophthalmoplegic migraine

  32. CASE PRESENTATION • D

  33. CASE PRESENTATION • Direct trauma

  34. CASE PRESENTATION • Direct trauma • Damage to the nerve endings • Damage to the iris sphincter muscle

  35. CASE PRESENTATION • D

  36. CASE PRESENTATION • Drugs

  37. CASE PRESENTATION • Drugs • Anticholinergics • Prototypical anti-Ch belladonna alkaloids • Atropine, scopolamine, hyoscyamine

  38. 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

  39. CASE PRESENTATION • What is the patient’s diagnosis?

  40. BRUGMANSIA

  41. CASE PRESENTATION • Brugmansia • Family Solinaceae • Atropa belladonna • Mandragora officinarium • Datura spp. • Brugmansia spp.

  42. BRUGMANSIA

  43. BRUGMANSIA

  44. BRUGMANSIA

  45. CASE PRESENTATION Emergency Medicine(2003) 15, 376-382 Isbister, Oakley, Dawson, Whyte Presumed Angel’s trumpet poisoning: Clinical effects and epidemiology

  46. CASE PRESENTATION • June 1990 – June 2000 • 33 patients • 31 recreational ingestion • 2 deliberate self-poisoning

  47. CASE PRESENTATION

  48. CASE PRESENTATION • Summary • Efferent pupillary defect • DDx: A, B, C, D, D • Anatomy & physiology & pathology • Brugmansia