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New-Onset Floaters as Presenting Symptom

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A patient in her 50s with a history of type 2 diabetes and mild bilateral nonproliferative diabetic retinopathy presented with new-onset floaters in both eyes but no blurry vision, eye pain, or photopsia. This patient was recently discharged from the hospital for West Nile virus (WNV) encephalitis (confirmed seropositive for IgM and IgG antibodies against WNV). Polymerase chain reaction analyses detected no DNA for Epstein-Barr virus, BK virus, cytomegalovirus, or herpes simplex virus types 1 and 2. Neither HIV antibody nor antigen was detected. Cerebrospinal fluid culture analysis findings were normal. She received supportive treatment and made a full recovery.

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West Nile virus chorioretinitis

D. Observe

This patient was diagnosed with WNV chorioretinitis based on the characteristic chorioretinitis lesions observed on clinical examination and diagnostic imaging, which are described below, and the confirmed diagnosis of WNV encephalitis. The most appropriate management is observation. Biopsy of the vitreous or the chorioretinal lesion is unlikely to yield additional diagnostic information, and the invasive procedure places the patient at risk for avoidable complications. Magnetic resonance imaging of the brain is unnecessary because it was recently performed when the patient was hospitalized for WNV encephalitis, and repeating the procedure will not provide additional clinical information.

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Article Information

Corresponding Author: Hang Pham, MD, Department of Ophthalmology, Saint Louis University Eye Institute, 1755 S Grand Blvd, St Louis, MO 63104 (hpham12@slu.edu).

Published Online: November 2, 2017. doi:10.1001/jamaophthalmol.2017.3504

Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
1.
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2.
Smithburn  KC, Hughes  TP, Burke  AW, Paul  JH.  A neurotropic virus isolated from the blood of a native of Uganda.  Am J Trop Med Hyg. 1940;s1-20(4):471-492.Google ScholarCrossref
3.
Campbell  GL, Marfin  AA, Lanciotti  RS, Gubler  DJ.  West Nile virus.  Lancet Infect Dis. 2002;2(9):519-529.PubMedGoogle ScholarCrossref
4.
Khairallah  M, Ben Yahia  S, Ladjimi  A,  et al.  Chorioretinal involvement in patients with West Nile virus infection.  Ophthalmology. 2004;111(11):2065-2070.PubMedGoogle ScholarCrossref
5.
Anninger  WV, Lomeo  MD, Dingle  J, Epstein  AD, Lubow  M.  West Nile virus–associated optic neuritis and chorioretinitis.  Am J Ophthalmol. 2003;136(6):1183-1185.PubMedGoogle ScholarCrossref
6.
Garg  S, Jampol  LM, Wilson  JF, Batlle  IR, Buettner  H.  Ischemic and hemorrhagic retinal vasculitis associated with West Nile virus infection.  Retina. 2006;26(3):365-367.PubMedGoogle ScholarCrossref
7.
Kahloun  R, Mbarek  S, Khairallah-Ksiaa  I, Jelliti  B, Yahia  SB, Khairallah  M.  Branch retinal artery occlusion associated with posterior uveitis.  J Ophthalmic Inflamm Infect. 2013;3(1):16.PubMedGoogle ScholarCrossref
8.
Learned  D, Nudleman  E, Robinson  J,  et al.  Multimodal imaging of West Nile virus chorioretinitis.  Retina. 2014;34(11):2269-2274.PubMedGoogle ScholarCrossref
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