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Unexplained Fever in Pregnancy

Dr. Rathinam Sivakumar Uveitis Services Consultant, Uveitis Service Aravind Eye Hospital Madurai India. Unexplained Fever in Pregnancy. General History. 26 year old lady, engineer sudden painless loss of vision in BE since 3 days fever and cough for two months

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Unexplained Fever in Pregnancy

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  1. Dr.RathinamSivakumar Uveitis Services Consultant, Uveitis Service Aravind Eye Hospital Madurai India Unexplained Fever in Pregnancy

  2. General History • 26 year old lady, engineer • sudden painless loss of vision in BE since 3 days • fever and cough for two months • cough was associated with haemoptysis • amenorrhea of 3 months,hospitalized and treated with ATT at general gynecology department. • Then referred to our hospital

  3. EXAMINATION

  4. Initial Diagnosis of Ocular Disease Retinal vascular occlusive disease of unknown origin

  5. Investigations • Hb: 7g% • WBC: 8,600 cells/cumm, platelets: 2 lakhs/cumm • ESR: 28mm at ½ hr, 55mm at 1 hr • Bleeding & Clotting Time : Normal • CRP: 22.9mg/ lit (N: up to 6 mg/l) • serum amylase: 91 IU/L (0 to 85 IU/L) • serum rheumatoid factor: 3.14 IU/ml (0 to 30) • plasma fibrinogen: 182 mg% • BL.glucose; sr creatinine; blood urea: WNL • PS: MICROCYTIC HYPOCHROMIC ANEMIA; • NEGATIVE FOR MALARIAL PARASITE • urine analysis: trace albumin

  6. Differential Diagnosis • Adamantiades – Behcet´s Disease • Polyarteriitisnodosa • Takayasu disease • Wegeners granulomatosis • syphilis • systemic lupus erythematosus

  7. History Review • h/o hair loss • h/o malar rash • occasional joint pains • no h/o oral or genital ulcers • no h/o headache • no h/o DM or HTN in self or family

  8. Diagnosis SLE Retinopathy

  9. Immediate Treatment • intravitreal triamcinolone acetate 0.1ml was given in BE as a first possible ocular treatment • as the patient was pregnant, she was referred to the Rheumatologist for systemic treatment

  10. Investigation • Rheumatologist for further invest.: • ANA: 9.2mg% (0.9 to 1.4mg%) • Anti Ds DNA; C3, C4; positive • Renal Function Test : WNL • Liver Function Test : WNL

  11. Therapy • all drugs have to be safe in pregnancy • prednisolone 40 mg • ecosprin 75mg • calcium supplement • blood transfusion 1 pint • Counseled for medical termination of pregnancy.

  12. medical termination of pregnancy was carried out. IV cyclophosphamide first cycle pulse methylprednisolone 1gm 3 days and maintained of oral prednisolone 1mg/kg body wt. Therapy – Follow-up

  13. Follow up – After 1 Week Persistent vasculitis and progressive cotton wool spots BE disc pallor and macular odema

  14. OD no glaucomatous disc damage Follow-up – After 1 Month • OU • resolved macular edema • no active vasculitis

  15. Follow-up – After 1 Month

  16. Therapy Revision for OD • Mycophenolate mofetil 1500mg /day • Prednisolone 20mg /day • Brimonidine 0.2% and • Timoptol 0.5%

  17. Patient shifted her residence and got lost for follow up for 6 months

  18. Follow-up – After 6 months • OD • Extensive vascular occlusion • resolved macular edema • Advised FFA

  19. SEVERE VASCULAR OCCLUSION WITH MACULAR ISCHEMIA

  20. NVD on the optic disc

  21. Therapy updated • PRP in 3 sitings for the OS • after discussion with rheumatologists: • Trental as vasodilatator • 400mg BD 15 days

  22. Follow-up – After 7 months • presented with sudden onset defective vision since two days in OS

  23. Follow-up – Ocular Examination FOLLOW UP ON JUNE,14TH 2010

  24. Ocular Examination • pale optic disc • sclerosed vessels • CWS • premacular hemorrhage • Pars PlanaVitrectomy with C3F8 under GVP

  25. Treatment • PPV+C3F8 under guarded visual prognosis

  26. Follow-up – After 8 months • Treatment was continued with immummunosuppressives and topical Dorzolamide 2% for the OD

  27. Follow-up – After 9 months

  28. Treatment • diode cyclophotocoagulation in OD • vitreous lavage in OS • she failed to follow-up.

  29. autoimmune, non-organ specific connective tissue disorder • 20% have ocular involvement • 90% are women, mostly of child bearing age • all age groups and both genders affected • ocular activity may occur independent of systemic activity • Lupus retinopathy is an imp marker of disease activity • ocular inflammatory lesions may precede extraocular manifestation by several months Discussion

  30. Conclusion • Although ocular involvement is benign, potentially blinding complications may occur. • Lupus retinopathy and neuro-ophthalmic involvement suggest systemic activity, therefore referral to a RHEUMATOLOGIST for management is mandatory. • Early diagnosis and timely institution of systemic therapy may minimize morbidity and mortality.

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