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Patricio Lorenzo Cruz Case Discussion 23A

Case 3

This is a 2 year old female who was brought in by her mother because of eye painover her right of 4 weeks duration. She noticed that her child keeps on crying mostof the time. There was no fever or loss of conciousness. No visual threat was elicitedover the right eye. Above is the clinical picture at the time of consult.

1. What is your differential diagnosis?Differential diagnoses include:

Retinopathy of prematurity Tuberculosis Anterior uveitis of childhood Vitreous hemorrhage Congenital cataract Exudative retinal detachment Retinoblastoma

Additional information. There is no family history of eye disease. An orbital CT scanwas done and is shown below

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2. What is your diagnosis?

Retinoblastoma is the most likely diagnosis for this patient, based on thepresentation of the child and the CT scan. The history does not lend muchclue into the disease, as most patients who develop retinoblastoma do not

have any positive history of retinoblastoma. The child exhibits leukocoria,strabismus, and red eye, which are manifestations of retinoblastoma. Theswelling of the upper eyelids is similar to that seen in orbital cellulitis;however, this does not necessarily indicate that there is already tumorinvolvement of the orbit. On the CT scan, a hyperlucent mass can be seen onthe medial aspect of the right eye, which may be the growing mass.

3. Why is the eye red and painful?The eye is red because of the presence of tortuous dilated blood vessels.Blood vessel formation is induced by the presence of the tumor, thus givingthe eye the red appearance. The pain is due to the inflammation caused

extraocular extension of the tumor, with the growing retinoblastomainvading the periocular tissues.

4. What are your plans in the management of this child?The treatment for the child is photocoagulation and cryotherapy.Photocoagulation is a possible option in treatment since the mass is stillsmall, and if the mass is located more posteriorly in the eye. However, thereis a risk in producing defects in the patients visual field post -treatment. If themass is located more anteriorly, cryotherapy can be used.

5. What are the histologic features of this disease?Histologic exam shows apoptotic cells can be seen between viable cells, withcalcifications often present. These calcifications are usually visible in x-rayfilms. These can help in diagnosing retinoblastoma.

Figure 1 Retinoblastoma micrograph.

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Characteristic of retinoblastoma is the presence of Flexner-Wintersteinerrosettes, which are composed of oval tumor cells surrounding a centrallumen, with the nuclei of the cells being peripherally displaced and thecytoplasm occupying the apices (towards the lumen). The presence of these

rosettes signifies neuroectodermal differentiation.

Figure 2 Flexner-Wintersteiner rosette. The central lumen is surrounded by tumor cells. The nuclei ofthe tumor cells (dark spots) can be seen in the periphery, while the apices of the cells remain largely

clear.

Case 4

This 20 year old male presented with pain on his right eye and forehead andblurring of vision for 3 days.

1. What questions would you ask him?It is important to ask the patient if he has had chicken pox already as a kid.He should also be asked if he is currently taking any medications, specificallyif he is taking corticosteroids in his regimen, or if he is currently underchemotherapy for cancer, as these medications will cause

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immunosuppression. His sexual history should also be looked into, if thereare any signs of exposure to HIV.

Additional information: He reported presence of fever and malaise for the past fewdays but no other symptoms. There was no previous episode of occurrence of the

said lesions and past ocular history of red eye or discomfort. The pain wascharacterized as lancinating and burning on the forehead and around the eye witheye pain and sensitivity to light.

2. What is the diagnosis?The most likely diagnosis for this patient is Herpes Zoster Ophthalmicus.Because the lesions are limited specifically to the right orbital region andright forehead and the characteristic of the lesions as vesicular andcontaining serous exudate, the disease is highly suspect. The region of thelesion coincides with the distribution of the ophthalmic division of thetrigeminal nerve (CN V), and Herpes Zoster is characterized by the

appearance of rashes and blisters along a distribution of a nerve.

Figure 3 Distribution of the branches of the trigeminal nerve. The distribution of the vesicular lesions inthe patient coincides with the distribution of the ophthalmic branch of the trigeminal nerve.

3. What would a lesion at the tip of the nose mean?The appearance of lesions at the tip of the nose is called the Hutchinson sign.This indicates that the nasociliary branch of the trigeminal nerve. TheHerpes Zoster has thus already involved the eye, since the nasociliary branchprovides sensory innervation to the globe, and provides sympatheticinnervation to the dilator muscles of the pupil.

4. What anterior segment eye findings would you look for?Anterior segment findings of Herpes Zoster Ophthalmicus include keratitis,conjunctivitis, belpharitis, iridocyclitis, iritis, and anterior uveitis. There canalso be atrophy of the iris and secondary glaucoma.

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5. How would you treat this patient?The main treatment for this patient is acyclovir 800 mg orally five times aday for seven to ten days. It is important that the patient be given theacyclovir within the day to prevent the occurrence of postherpetic neuralgia.

To address the pain and edema caused by the lesions, 40-60 mg ofprednisolone can also be given. This must be tapered over the ten-daycourse.