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Grand Rounds Conference
Lara Rosenwasser Newman, MDUniversity of Louisville
Department of Ophthalmology and Visual Sciences
December 5, 2014
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SubjectiveCC: Red eyes and eyelids, eyes
burning x 2 days
HPI: 51 yo WM, inpt for dyspnea, dysphagia, who began to have burning in his eyes, red eyes, and redness and burning of the skin around the eyes, progressively worsening over 2 days.
Had upper endoscopy 2 days prior, awaiting path. Felt that placing cold washcloth over eyes helped. Primary team had placed on cipro gtts x1 day.
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HistoryPMHx:
Barrett’s esophagus, esophageal cancer, COPD
per pt Hep C treated w/IFN, in remission since 2004 or 2005
PSHx: Multiple upper endoscopies, Nissen
fundoplicationPOHx:
PresbyopiaMedications:
At home: Paxil, Prilosec, Singulair, albuterol inhaler
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History Continued
Medications as inpatient: Dilaudid, morphine, Zofran 1x doses
atropine/hyoscyamine/PB/scopolamine, GI cocktail, hydroxide/Mg hydroxide/simethicone
Lovenox, hydromorphone, lidocaine morphine
Pantoprazole, Paxil Cipro 2 gtts OU q4h while awake Rocephin 1g daily Flu shot
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IOP (tonopen):18mmHg18mmHg
EOM:
Clinical Exam OD OSVA (near, +2.00s): 20/25 20/20
Pupils: 2.51.5 2.51.5
0
0
0
0
(-) rAPD
0
0
0
0
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Clinical ExamPLE: External/Lids Erythema lower>upper lids, red-racoon- eyes appearance, skin rough/sandpapery, mild edema, not induratedConjunctiva/Sclera Severe injected OU, did not blanche w/ phenylephrine, mucoid dischargeCornea diffuse fine SPEs on fluoresceinAnterior Chamber Formed OUIris Normal OULens Clear OUVitreous Normal OU
DFE: ON pink & sharp OU, M/V/P WNL
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External Appearance
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Approx 1 cm excoriated plaque on posterior left neck, no other skin lesions
Afebrile, stable vitals
Mucoid to purulent appearing discharge, sent for aerobic and anaerobic cultures Final results: negative
Exam continued
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Assessment
51 yo WM w/dysphagia, chest pain, dyspnea, presenting with acute dermatoblepharoconjunctivitis.
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Differential Considerations
Contact dermatoconjunctivitis Detergent hospital uses for washcloths?
Dermatomyositis Preseptal cellulitis
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Plan
Discontinue Cipro gtts Aggressive lubrication
w/preservative-free artificial tears q2-4 hrs
Follow-up cultures (negative)
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Follow-up
Resolved over next several days Pt was discharged days later
Surg path from upper endoscopy: Barrett’s, otherwise benign
Symptoms attributed to gastroparesis, gastritis/esophagitis
Now in hospital again for dyspnea, dysphagia, and chest pain
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Review of 215 pts who presented for eyelid dermatitis in a 42 month period 165 allergic contact dermatitis (personal care
products, metals) 9 protein contact dermatitis (no positive patch
test) 35 atopic eczema (33 of these also had contact
allergies) 35 psoriasis or seborrheic dermatitis or both 5 rosacea or periorbital dermatitis 2 dermatomyositis
Guin JD. Eyelid dermatitis: a report of 215 patients. Contact Dermatitis. 2004 Feb;50(2):87-90. PubMed PMID: 15128319.
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Contact dermatitis Most common eruption of eyelid Can involve lids & eyes
Unilateral or symmetrical Pruritic, scaling erythematous eruption
of lid(s) May see periorbital edema, blepharitis,
conjunctivitis Watery discharge, papillary or follicular conj
rxn Allergic (pruritus) or irritant
(burning/stinging) Can be very difficult to distinguish
between 3 top causes: cosmetics, topical
ophthalmic meds, CL solutions
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Provocative substances
Drugs Cosmetics/personal care products
including nail polish, hand soap Preservatives Dyes Plant resins Heavy metals Plastic or nickel in glasses
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Contact dermatitis
Dx: patch testing, clinical picture Tx: identify/eliminate offending
allergen/irritant Cool compresses Topical corticosteroids Oral antihistamines
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Contact Dermatitis
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Dermatomyositis Systemic vascular disorder
Skin & muscle inflammation, acute or insidious
Atonic, weak, achy proximal muscle groups Gottron’s papules = diagnostic
Flat-topped erythematous papules over knuckles
Scaly areas on backs of hands, knuckles, elbows, knees, and nail changes (shininess, erythema)
Telangiectasia, skin rash in malar region, neck, shoulders, upper chest, and back
Assoc w/breast, ovary, lung, pancreas, stomach, colon, rectum CA & NHL (18-32% of DM pts)
Can have GI & respiratory involvement
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Dermatomyositis Etiology: unknown
Genetic susceptibility + exposure to environmental agents or cancers immune activation/inflam
Injury to capillaries & myofibers 2 theories:
Induction of type 1 IFN-inducible gene products
Antibody & complement-mediated microangiopathy
AutoAbs incl myositis-specific Abs (MSAs)
Can be precipitated/caused by penicillins, sulfonamides, and D-penicillamine
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Dermatomyositis Dx: muscle biopsy Labs:
High transaminases, CK, aldolase, LDH sometimes (+) ANA, anti-Jo-1, anti-Mi-2,
RF
Tx: systemic corticosteroids, usually w/satisfactory response in classic DMS Less so in pts w/anti-Jo Abs If steroids fail, cytotoxic agents (MTX,
azathioprine) and/or IVIG
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Dermatomyositis Features
Credit: Ostler, HB, Maibach, HI, Hoke, AW, and Schwab, IR. Diseases of the Eye & Skin: A Color Atlas. Philadelphia, PA; Lippincott Williams & Wilkins, 2004: 14-19 and 112-122.
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DM – Ocular Findings
Heliotrope telangiectasias of eyelids = characteristic
CONJ CHEMOSIS = COMMON
Can cause nonspecific conjunctivitis, rarely pseudomembranous conjunctivitis
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Dermatomyositis Features
Credit: Ostler, HB, Maibach, HI, Hoke, AW, and Schwab, IR. Diseases of the Eye & Skin: A Color Atlas. Philadelphia, PA; Lippincott Williams & Wilkins, 2004: 14-19 and 112-122.
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Dermatomyositis Features
Credit: Mannis, MJ, Macsai, MS, Huntley, AC. Eye and Skin Disease. Philadelphia, PA; Lippincott-Raven Publishers, 1996: 233-238.
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DM – Ocular Findings Nonspecific episcleritis or scleritis Exophthalmos Anterior uveitis Retinopathy w/cotton wool spots Late sequelae of pigmentary
maculopathy & optic atrophy EOM paralysis and nystagmus Rare but important: orbital
polymyositis or ocular myositis assoc w/giant-cell myocarditis
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References1. Park IK, Chun YS, Kim KG, Yang HK, Hwang JM. New clinical grading scales and objective
measurement for conjunctival injection. Invest Ophthalmol Vis Sci. 2013 Aug 5;54(8):5249-57. doi: 10.1167/iovs.12-10678. PubMed PMID: 23833063.
2. Ostler, HB, Maibach, HI, Hoke, AW, and Schwab, IR. Diseases of the Eye & Skin: A Color Atlas. Philadelphia, PA; Lippincott Williams & Wilkins, 2004: 14-19 and 112-122.
3. Mannis, MJ, Macsai, MS, Huntley, AC. Eye and Skin Disease. Philadelphia, PA; Lippincott-Raven Publishers, 1996: 233-238.
4. Guin JD. Eyelid dermatitis: a report of 215 patients. Contact Dermatitis. 2004 Feb;50(2):87-90. PubMed PMID: 15128319.
5. Ebert EC. Review article: the gastrointestinal complications of myositis. Aliment Pharmacol Ther. 2010 Feb 1;31(3):359-65. doi: 10.1111/j.1365-2036.2009.04190.x. Epub 2009 Nov 3. Review. PubMed PMID: 19886949.
6. Iaccarino L, Ghirardello A, Bettio S, Zen M, Gatto M, Punzi L, Doria A. The clinical features, diagnosis and classification of dermatomyositis. J Autoimmun. 2014 Feb-Mar;48-49:122-7. doi: 10.1016/j.jaut.2013.11.005. Epub 2014 Jan 24. Review. PubMed PMID: 24467910.
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Dermatomyositis: Resp & GI
Dysphagia from involvement of muscles of tongue, pharynx, & upper 1/3 of esophagus Can get dysphagia for liquids and solids Pharyngeal and upper esophageal
involvement can cause asphyxiation and/or aspiration
Nasal regurgitation characteristic nasal voice
Muscles of respiration and myocardium may also be affected
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Dermatomyositis can be associated with: Crohn’s/UC (IBD) Celiac (may respond to gluten-free diet) Hep C virus Primary biliary cirrhosis
Can develop during IFN tx of HCV Usually resolves w/discontinuation of
IFN Myopathies can occur during tx
w/PPIs Mentions polymyositis & rhabdo