The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.01.031
Clinical Communications: Pediatrics OPHTHALMIC PRESENTATION IN THE EMERGENCY DEPARTMENT: A CASE REPORT OF A GIRL WITH ‘‘SHIMMERING EYES’’ Roman Krivochenitser, MS,* Yonatan Lemma, MD,† Barbara Wynn, MD,† and Jeffrey S. Jones, MD† *Michigan State University College of Human Medicine, Grand Rapids, Michigan and †Michigan State University Program in Emergency Medicine, Spectrum Health Hospital–Butterworth Campus, Grand Rapids, Michigan Reprint Address: Roman Krivochenitser, MS, Michigan State University College of Human Medicine, 205 Morris Ave SE, Grand Rapids, MI 49503
, Abstract—Background: Ophthalmic complaints are commonplace in the emergency department (ED) and are often initial presentations of a systemic illness. We present a 2-year-old girl presenting to the ED with ataxia and ‘‘shimmering’’ eyes. Case Report: The patient was diagnosed with opsoclonus-myoclonus syndrome (OMS) involving involuntary, multi-vectorial (mostly horizontal), conjugate fast eye movements without intersaccadic intervals. The ophthalmic presentation led to a paraneoplastic work-up, which revealed an abdominal mass measuring 5.3 3.3 4.3 cm, suggestive of neuroblastoma. The patient’s opsoclonus improved after a 5-day course of dexamethasone and intravenous immunoglobulin. Why should an emergency physician be aware of this?: This case illustrates the importance of recognizing pathognomonic ophthalmic complaints in the ED. We present an overview of classic ophthalmic presentations associated with systemic illnesses. Ó 2014 Elsevier Inc.
and knowledge of their associated conditions should trigger a systematic work-up in the ED to ensure a diagnosis is not missed. We present a case in the ED where a classic eye finding was the main presenting symptom that lead to an otherwise difficult diagnosis. CASE REPORT The patient was a previously healthy 2-year-old girl presenting to the ED with a chief complaint of increasing gait imbalance of 3 days duration. One week prior to admission, the patient presented to her primary care physician for weakness and was noted to have vaginal redness. She was suspected to have a urinary tract infection at that time and was prescribed cephalexin. The parents later noted that the patient was not acting herself and the cephalexin was discontinued for fear of a drug reaction. The patient progressively became ‘‘wobbly’’ as she walked. One day prior to admission, the parents noted that the patient was falling over even while crawling, and had ‘‘shaking spells’’ of her extremities in the morning. At that time, the father noticed that the patient’s eyes were ‘‘shimmering.’’ The patient was born at full term with no complications. Her immunizations were up to date and the patient had met all of her developmental milestones. The parents denied any fever, chills, headaches, nausea, vomiting, congestion, diarrhea, or abdominal pain. There were no
, Keywords—opsoclonus-myoclonus; neuroblastoma; paraneoplastic; emergency department; eye complaints
INTRODUCTION Ophthalmic disturbances are a common component of many systemic disorders. In acute care settings, such as the emergency department (ED), a typical eye finding may be the only presentation of a developing lifethreatening illness. Recognition of specific eye findings
RECEIVED: 9 August 2013; FINAL SUBMISSION RECEIVED: 4 November 2013; ACCEPTED: 31 January 2014 1
2
recent sick contacts. Past medical, surgical, and family history were unremarkable. On physical examination, the patient was calm, well nourished, in no acute distress, resting in her mother’s arms. Her vital signs were: temperature 36.9 C (98.4 F), pulse 114 beats/min, respiratory rate 24 breaths/min, blood pressure 112/65 mm Hg, pulse oximetry 100% on room air, and weight 15.3 kg. Cranial nerves II–VII were intact, as well as extraocular eye movements. Pupils were equal, round, and reacted to light. The patient demonstrated rapid, involuntary, multi-vectorial (mostly horizontal), conjugate fast eye movements without intersaccadic intervals. Her Babinski sign was downgoing. The patient was unable to ambulate unassisted. She became frustrated when she lost balance and was having difficulty sitting up by herself. The patient was happy to walk with handholding assist and displayed a widebased gait with truncal instability. The remainder of the physical examination was unremarkable. Due to the opsoclonus with ataxia, the patient was admitted to the hospital and a work-up of neuroblastoma and cerebellitis was pursued. A complete blood count, complete metabolic panel with liver function tests, urine metanephrines, and an abdominal ultrasound were ordered. The admitting team opted for a magnetic resonance imaging (MRI) study of the brain instead of an initial computed tomography (CT) scan of the head. Blood counts were within normal limits, including a white blood cell count of 7.87 (5.5–15.5 103/mL) and hemoglobin of 12.2 (11.5–15. 5 g/dL). Urine metanephrines, including urine vanillylmandelic acid and urine homovanillic acid, were elevated to 49.7 mg (
http://dx.doi.org/10.1016/j.jemermed.2014.01.031
Clinical Communications: Pediatrics OPHTHALMIC PRESENTATION IN THE EMERGENCY DEPARTMENT: A CASE REPORT OF A GIRL WITH ‘‘SHIMMERING EYES’’ Roman Krivochenitser, MS,* Yonatan Lemma, MD,† Barbara Wynn, MD,† and Jeffrey S. Jones, MD† *Michigan State University College of Human Medicine, Grand Rapids, Michigan and †Michigan State University Program in Emergency Medicine, Spectrum Health Hospital–Butterworth Campus, Grand Rapids, Michigan Reprint Address: Roman Krivochenitser, MS, Michigan State University College of Human Medicine, 205 Morris Ave SE, Grand Rapids, MI 49503
, Abstract—Background: Ophthalmic complaints are commonplace in the emergency department (ED) and are often initial presentations of a systemic illness. We present a 2-year-old girl presenting to the ED with ataxia and ‘‘shimmering’’ eyes. Case Report: The patient was diagnosed with opsoclonus-myoclonus syndrome (OMS) involving involuntary, multi-vectorial (mostly horizontal), conjugate fast eye movements without intersaccadic intervals. The ophthalmic presentation led to a paraneoplastic work-up, which revealed an abdominal mass measuring 5.3 3.3 4.3 cm, suggestive of neuroblastoma. The patient’s opsoclonus improved after a 5-day course of dexamethasone and intravenous immunoglobulin. Why should an emergency physician be aware of this?: This case illustrates the importance of recognizing pathognomonic ophthalmic complaints in the ED. We present an overview of classic ophthalmic presentations associated with systemic illnesses. Ó 2014 Elsevier Inc.
and knowledge of their associated conditions should trigger a systematic work-up in the ED to ensure a diagnosis is not missed. We present a case in the ED where a classic eye finding was the main presenting symptom that lead to an otherwise difficult diagnosis. CASE REPORT The patient was a previously healthy 2-year-old girl presenting to the ED with a chief complaint of increasing gait imbalance of 3 days duration. One week prior to admission, the patient presented to her primary care physician for weakness and was noted to have vaginal redness. She was suspected to have a urinary tract infection at that time and was prescribed cephalexin. The parents later noted that the patient was not acting herself and the cephalexin was discontinued for fear of a drug reaction. The patient progressively became ‘‘wobbly’’ as she walked. One day prior to admission, the parents noted that the patient was falling over even while crawling, and had ‘‘shaking spells’’ of her extremities in the morning. At that time, the father noticed that the patient’s eyes were ‘‘shimmering.’’ The patient was born at full term with no complications. Her immunizations were up to date and the patient had met all of her developmental milestones. The parents denied any fever, chills, headaches, nausea, vomiting, congestion, diarrhea, or abdominal pain. There were no
, Keywords—opsoclonus-myoclonus; neuroblastoma; paraneoplastic; emergency department; eye complaints
INTRODUCTION Ophthalmic disturbances are a common component of many systemic disorders. In acute care settings, such as the emergency department (ED), a typical eye finding may be the only presentation of a developing lifethreatening illness. Recognition of specific eye findings
RECEIVED: 9 August 2013; FINAL SUBMISSION RECEIVED: 4 November 2013; ACCEPTED: 31 January 2014 1
2
recent sick contacts. Past medical, surgical, and family history were unremarkable. On physical examination, the patient was calm, well nourished, in no acute distress, resting in her mother’s arms. Her vital signs were: temperature 36.9 C (98.4 F), pulse 114 beats/min, respiratory rate 24 breaths/min, blood pressure 112/65 mm Hg, pulse oximetry 100% on room air, and weight 15.3 kg. Cranial nerves II–VII were intact, as well as extraocular eye movements. Pupils were equal, round, and reacted to light. The patient demonstrated rapid, involuntary, multi-vectorial (mostly horizontal), conjugate fast eye movements without intersaccadic intervals. Her Babinski sign was downgoing. The patient was unable to ambulate unassisted. She became frustrated when she lost balance and was having difficulty sitting up by herself. The patient was happy to walk with handholding assist and displayed a widebased gait with truncal instability. The remainder of the physical examination was unremarkable. Due to the opsoclonus with ataxia, the patient was admitted to the hospital and a work-up of neuroblastoma and cerebellitis was pursued. A complete blood count, complete metabolic panel with liver function tests, urine metanephrines, and an abdominal ultrasound were ordered. The admitting team opted for a magnetic resonance imaging (MRI) study of the brain instead of an initial computed tomography (CT) scan of the head. Blood counts were within normal limits, including a white blood cell count of 7.87 (5.5–15.5 103/mL) and hemoglobin of 12.2 (11.5–15. 5 g/dL). Urine metanephrines, including urine vanillylmandelic acid and urine homovanillic acid, were elevated to 49.7 mg (
