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

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

EXAMINATION VA DISTANCE NEAR 3/60 NIG or PH N36 at 25cm 3/60 NIG or PH ANTERIOR SEGMENT CORNEA CLEAR ANT.CHAMBER ND ,QUIET IRIS NCP PUPIL REACTION ILLSUSTAINED LENS EOM FULL EXAMINATION

BE MEDIA CLEAR; NO VIT HAZE DISC DISC ODEMA VESSELS SHEATHING OF VESSELS;ACTIVE VASCULITIS MACULA DULL FR BACKGROUND RETINA MULTIPLE COTTON WOOL SPOTS; MULTIPLE SPLINTER HAGE

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

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

Differential Diagnosis Adamantiades – Behcet´s Disease Polyarteriitis nodosa Takayasu disease Wegeners granulomatosis syphilis systemic lupus erythematosus

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

Diagnosis SLE Retinopathy

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

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

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.

Therapy – Follow-up 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.

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

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

Follow-up – After 1 Month RE LE Vision DISTANCE NEAR 2/60 6/60 PH 6/18P (Untreated with TCA) N 12 at 33 cm IOP (mm Hg) 30 12

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

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

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

SEVERE VASCULAR OCCLUSION WITH MACULAR ISCHEMIA

NVD on the optic disc

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

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

Follow-up – Ocular Examination VISION ½ /60 HAND MOVEMENTS CORNEA CLEAR AC SHALLOW ND PUPIL 5mm FIXED 3mm SLUGGISH lRIS ECTROPION UVEA; NVI;PAS NCP LENS PSCC IOP 42 12 FUNDUS CDR:0.8, inf NRR thinning NVE; Media hazy DISPERSED VH FOLLOW UP ON JUNE,14TH 2010

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

Treatment PPV+C3F8 under guarded visual prognosis

Follow-up – After 8 months RE LE VISION 1/60 6/12 IOP (mmHg) 36 15 Treatment was continued with immummunosuppressives and topical Dorzolamide 2% for the OD

Follow-up – After 9 months RE LE VISION 1/60 6/9p IOP(mm Hg) 18 10

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

Discussion 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

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.