Hearing loss, uveomeningitis, and stroke in a 55‐year‐old man

Abstract

A 55-year-old Cuban-born man presented to the emergency room with hearing loss and bilateral visual loss. History of the present illnessThe patient had been in his usual state of good health until 4 -6 weeks prior to presentation, when he began to develop steadily decreasing vision in both eyes and severe, bilateral hearing loss. He also experienced extreme photophobia, eye redness, pain, and frontal headache. On presentation to the emergency room, he reported almost no hearing in the right ear and very little hearing in the left ear. Prior to the development of visual symptoms, he had experienced sinus pressure and drainage, which he attributed to a sinus infection. He denied fevers, tinnitus, or neck pain. Medical historyThe patient's medical history was significant for occasional back pain. Family and social historiesThe patient reported a 6 pack-year history of smoking. He also reported occasional cocaine, marijuana, and LSD use, but denied use of intravenous drugs and alcohol. He denied any family history of autoimmune disease or ophthalmic conditions. Physical examinationThe patient was a well-nourished Cuban man who was squinting in ambient lighting. His vital signs were stable with a temperature of 37.1°C, blood pressure of 111/70 mm Hg, pulse of 78 beats per minute, and a respiration rate of 18 breaths per minute. The cardiac, lung, abdomen, and extremity examinations were unremarkable. Skin examination showed no rashes and no evidence of vasculitis. There was no swelling, erythema, or synovitis in the hands, wrists, elbows, shoulders, knees, or ankles. Genitourinary examination revealed mild inguinal lymphadenopathy bilaterally, which was thought to be a benign finding. The neurologic examination revealed normal sensorimotor findings, negative Romberg's sign, steady gait, and normal 2ϩ deep tendon reflexes bilaterally. The patient was unsteady with tandem gait. Heel-to-shin and rapid alternating movements were unremarkable.Ophthalmic examination revealed a visual acuity of 20/ 400 in the right eye and 20/70 in the left eye. The pupils, to the extent that they could be seen through edematous corneas, appeared sluggishly reactive to light and showed no relative afferent pupillary defect. The ocular motility was normal in both eyes. Slit-lamp examination showed mild diffuse perilimbal and bulbar conjunctival injection, diffuse corneal edema predominantly involving the corneal stroma, severe (3ϩ) anterior chamber cellular inflammation, normal irides, and mild cataracts in both eyes. The fundus was poorly visualized due to the corneal edema. No optic disc edema was observed in either eye. The macula, vessels, and peripheral retina were grossly normal in the right eye and unremarkable in the left eye. The intraocular pressures were elevated in both eyes at 42 mm Hg in the right eye and 27 mm Hg in the left eye (normal range 9 -22).Otologic examination showed clear tympanic membranes. No evidence of erythema or fluid was visible behind the tympanic membranes on both sides. The umbo appeared normal in both ear...