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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


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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