Grand Rounds Conference

Lara Rosenwasser Newman, MDUniversity of Louisville

Department of Ophthalmology and Visual Sciences

December 5, 2014

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.

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

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

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

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

External Appearance

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

Assessment

51 yo WM w/dysphagia, chest pain, dyspnea, presenting with acute dermatoblepharoconjunctivitis.

Differential Considerations

Contact dermatoconjunctivitis Detergent hospital uses for washcloths?

Dermatomyositis Preseptal cellulitis

Plan

Discontinue Cipro gtts Aggressive lubrication

w/preservative-free artificial tears q2-4 hrs

Follow-up cultures (negative)

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

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.

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

Provocative substances

Drugs Cosmetics/personal care products

including nail polish, hand soap Preservatives Dyes Plant resins Heavy metals Plastic or nickel in glasses

Contact dermatitis

Dx: patch testing, clinical picture Tx: identify/eliminate offending

allergen/irritant Cool compresses Topical corticosteroids Oral antihistamines

Contact Dermatitis

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

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

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

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.

DM – Ocular Findings

Heliotrope telangiectasias of eyelids = characteristic

CONJ CHEMOSIS = COMMON

Can cause nonspecific conjunctivitis, rarely pseudomembranous conjunctivitis

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.

Dermatomyositis Features

Credit: Mannis, MJ, Macsai, MS, Huntley, AC. Eye and Skin Disease. Philadelphia, PA; Lippincott-Raven Publishers, 1996: 233-238.

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

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.

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

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