Syphilitic panuveitis and optic neuritis
A. Obtain HIV and syphilis serology results
In this patient with hemorrhagic optic neuritis and evidence of panuveitis, infection must first be ruled out before initiating any systemic corticosteroids (choice A). A patient with a history of drug use and many sexual partners further supports ruling out an infection, particularly syphilis and HIV. Idiopathic demyelinating optic neuritis is a common cause of optic nerve edema with abnormal visual function in patients younger than 50 years, although it typically does not present with panuveitis.1 Therefore, beginning methylprednisolone would not be appropriate without proper systemic workup (choice B). Cytomegalovirus optic neuritis should be on the differential diagnosis for any patient with substantial risk factors for HIV/AIDS, although there were no signs suggestive of cytomegalovirus retinitis on examination and therefore treatment with foscarnet is not appropriate (choice C). Intracranial imaging may be warranted in the evaluation of papilledema, but magnetic resonance imaging of the brain would be more appropriate than computed tomography of the head, as it better detects optic neuritis and cerebrospinal fluid outflow obstructions (choice D).1 Additionally, his subsequent blood pressure measurements lowered and his initial reading was felt to be transient in the setting of an emergency visit, and thus, hypertension was not felt to be the causative etiology.