Male, 73 years old.
Diagnosed with CML in September 2024 after an accidental finding of leukocytosis.
He was treated with dasatinib, which was stopped on 10th April.
Mid March he noticed a bilateral loss of vision.
On 11th April he got his first eye exam which revealed a bilateral optic disc edema
He was given oral methylprednisolone 64 mg/day.
Bloodwork and cerebral MRI were considered normal.
The hematologist considered the CML to be in remission and therefore unlikely to be the cause.
During follow-up in the next two weeks the optic disc edema resolved. Despite that, he continued to have further loss of vision and visual field in the right eye. The left eye mostly remained non-functional.
With a bit of fantasy, one might wonder if there is a quadrantanopsia in the right eye initially (and then a hemianopia??) against a background of diffuse loss of sensitivity.
Until now there has been no explanation for his going blind.
Lumbar puncture was refused by the hematologist as it was deemed unnecessary. The neurologist eventually did the LP after explaining its importance.
The results of the lumbar puncture read: "Cell-rich cytological sample with a predominance of lymphoid cells, which sometimes show varying diameters. No cytological evidence of an underlying epithelial lesion. Results must be strictly correlated with clinical biology to rule out an underlying lymphoma."
Despite that, the hematologist said that the lumbar puncture was traumatic and that this explains this result. They reassured us that the leukemia is inactive.
He is now coming to me for second opinion.
My current DD would be:
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Giant cell arteritis (biopsy tomorrow, as the diagnosis had not been considered before, because of normal CRP and ESR)
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Microscopic leukemic optic nerve infiltration
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Paraneoplastic optic neuropathy
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Dasatinib causing optic neuropathy has been described
My suggested approach would be:
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Repeat lumbar puncture
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MRI orbits
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Plasmapheresis depending on results of the second lumbar puncture
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Optic nerve biopsy if all else fails, his vision is not stable and the patient agrees
Would do you think?...
Since this is quite an aggressive approach, I do not feel too comfortable about this, but neither is the progression of his visual fields
Michel
PS.
- I was told, I am allowed to post images directly using this new medium - if not, please let me know
- Apologies if this is a double thread (I first tried starting one by sending an e-mail, but it probably/obviously does not work like that)