Neurology Case Challenge: A 19-Year-Old With Tinnitus, Vision Problems, and Headaches

Sumaira Nabi, MBBS; Muhammad Fateen Rashid, MBBS; Shahzad Ahmed, MBBS


May 31, 2022

Physical Examination and Workup

Upon physical examination, she is conscious, cooperative, and well oriented to time, place, and person. Her vital signs include an oral temperature of 98.6°F (37°C), a regular pulse of 74 beats/min, and a blood pressure of 110/80 mm Hg. Her respiratory rate is 16 breaths/min.

Upon neurologic examination, using the measurement of meters wherein 6/6 is the equivalent of 20/20 using the customary US units of feet, the visual acuity in both eyes is reduced to 6/12. She has sixth nerve palsy on the left side. Funduscopic examination reveals bilateral optic disc swelling (see Figure 1).

Figure 1.

The other cranial nerves are intact and symmetric. Her neck is supple with full range of motion. No signs of pyramidal weakness or incoordination are present. Her abdomen is soft and nontender. No clinical evidence suggests organomegaly or ascites. Her bowel sounds are audible. The patient's precordial examination findings reveal normal heart sounds. Auscultation of the lung fields shows normal vesicular breathing.

The laboratory analysis reveals a normal complete blood cell (CBC) count and erythrocyte sedimentation rate. Her liver function test results, renal function test results, serum glucose levels, urinalysis findings, ECG findings, and chest radiography findings are unremarkable. Laboratory test findings for rheumatoid factor (RA) and antinuclear antigen (ANA) are negative. Her lumbar puncture has an opening pressure of 300 mm H20 (reference range, 70-180 mm Hg), and her CSF analysis findings are normal.

MRI of the brain with contrast reveals intraocular protrusion of the left optic nerve head with increased tortuosity of the optic nerves on axial T2-weighted imaging (see Figure 2). No meningeal enhancement or parenchymal lesion is noted.

Figure 2.

Magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) of the head are found to be normal. Goldmann perimetry reveals an enlarged blind spot.


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