A 50-year-old African American female presented with a three-week history of intractable headache, confusion, vertical binocular diplopia, photophobia, and difficulty with balance. Examination revealed best corrected visual acuities of 20/25 in the right eye (OD) and 20/20 in the left eye (OS) with intraocular pressures (IOP) of 14 mmHg in both eyes (OU). No afferent pupillary defect was noted, extraocular motility (EOM) was full OU, and confrontational visual fields were full OU. Anterior segment examination in both eyes was unremarkable. Funduscopic examination of both eyes revealed grade-four optic disc edema, blurring of optic disc margin, and obscuration of vasculature of the optic nerve. Preretinal and intraretinal hemorrhages were present in both eyes, largely concentrated in the peripapillary retina, but extending to the mid-peripheral retina (Figures and ). Optic nerve swelling was confirmed on optical coherence tomography (OCT) of the retinal nerve fiber layer (Figures and ). Fluorescein angiography revealed hyperfluorescence of the optic disc OU (Figures and ).\nComputed tomography of the head, magnetic resonance imaging of the brain, and magnetic resonance venography of the brain were unremarkable and had no evidence of intracranial mass, hemorrhage, or ischemia. Cerebrospinal fluid (CSF) analysis revealed an opening pressure of 30 cm H2O, 77 white blood cells/mm3 with 94% lymphocytes, 93 mg/dL protein, and 73 mg/dL glucose. Bacterial and fungal cultures of the CSF were negative. CSF studies for Lyme, syphilis, herpes simplex virus, and West Nile virus were unremarkable. A limited panel consisting of laboratory studies for enterovirus, syphilis, ANA, and p-ANCA was negative. A respiratory viral panel for adenovirus, cytomegalovirus, influenza, parainfluenza, rhinovirus, and respiratory syncytial virus was negative on Polymerase Chain Reaction testing. Based on the patient's presentation and cerebrospinal fluid findings, she was diagnosed with viral meningoencephalitis. She was monitored as an inpatient with conservative management. During the hospital course, the patient noted improvement in her double vision and headaches. A repeated lumbar puncture 5 days later revealed opening pressure of 4 cm H2O, 38 white blood cells/mm3, 75 mg/dL protein, and 57 mg/dL glucose. The patient was subsequently discharged from the hospital.\nFollow-up examinations with serial OCT of the optic nerve showed continued progressive improvement in disc edema (Figures –) along with complete resolution of papilledema and peripapillary hemorrhages (Figures –). Mild residual pallor of both optic nerves was observed at the end of one year. OCT revealed borderline temporal thinning of the right optic nerve. The left optic nerve had borderline temporal thinning, borderline superotemporal thinning, and inferotemporal thinning. The findings of persistent disc pallor and inferotemporal nerve fiber layer thinning on OCT were consistent with the persistent visual field deficit documented on Humphrey visual fields (Figures –).
A 48-year-old male presented with complaints of severe headache of two-week duration. The headache was in the right parietal region accompanied by nausea and vomiting. There was neither any history of fever, photophobia, blurring of vision or diplopia, nor any significant past medical history. He was previously seen in another hospital; the brain Computed Tomography (CT) scan was reported to be normal.\nOn physical examination, the vital signs were within normal limits, and the patient was afebrile. Mental status examination did not reveal any abnormality. On clinical examination of the motor system, the tone and power in all the four limbs were normal with exaggerated (3+) reflexes. There was no neck stiffness, and Kernig’s sign was negative. Gait and coordination were normal. The sensory system and the cranial nerves were normal. Fundoscopy did not reveal any abnormality. No significant finding was revealed in other systemic examinations.\nRoutine full blood count and biochemistry did not show any abnormality. However, enzyme-linked immunosorbent assay (ELISA) of the patient’s serum was positive for anti- herpes simplex virus (HSV) IgM antibody. Lumbar puncture was not carried out since the patient refused it. The electroencephalogram (EEG) did not reveal any abnormality. The Magnetic Resonance Imaging (MRI) brain revealed bright T2/FLAIR cortical images at right parietal and temporal region ().\nA presumptive diagnosis of herpes simplex encephalitis (HSE) was made on the basis of serological and MRI findings; empirical treatment with intravenous acyclovir 750 mg eight hourly was initiated. He also received hydrocortisone 8 mg intravenous followed by oral prednisolone 40 mg daily. The headache was relieved, and the patient had no complaint while in the ward. A repeat brain MRI, which was done one week later, showed that the cortical enhancement has markedly reduced indicating response to treatment (). On discharge the patient was advised to repeat MRI and EEG after one week.\nThree weeks after the initial admission, the patient presented again with complaints of right retro-orbital pain of two days duration. The pain was accentuated with eye movements. The patient also noticed that he could not see clearly with the affected eye. Clinical examination revealed red colour desaturation and reduced visual acuity. Ophthalmoscopic examination showed a swollen right optic disc. Visual evoked potential (VEP) revealed small amplitude and delay in the right P100 latency (right: 122.40 ms, left: 113.10 ms). Right optic neuritis was diagnosed, which was treated with intravenous methylprednisolone 250 mg six hourly. The right eye pain was relieved, and the vision gradually improved. A diagnosis of post encephalitic right optic neuritis was made.