Endgames Case Review

A 22 year old woman with bilateral panuveitis and parotid swelling

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4178 (Published 11 August 2015) Cite this as: BMJ 2015;351:h4178
  1. James Lowe, foundation year 2 doctor1,
  2. Ben Whatley, foundation year 2 doctor1,
  3. Shahram Kashani, consultant ophthalmologist1,
  4. David Howlett, consultant radiologist2
  1. 1Department of Ophthalmology, Eastbourne District General Hospital, Eastbourne BN21 2UD, UK
  2. 2Department of Radiology, Eastbourne District General Hospital
  1. Correspondence to: J Lowe james.lowe1{at}nhs.net

A 22 year old white woman presented with a three month history of bilateral red eyes and severely reduced vision in her left eye. The vision loss had occurred a few weeks before presentation. She had recently seen her general practitioner because of weight loss and facial swelling, and had been experiencing night sweats and reduced exercise tolerance related to fatigue.

Before this presentation she had been well. She was a non-smoker and worked as a hairdresser. She had no pets, no recent travel history, and no other history of note. On examination she was thin and pale and her best corrected Snellen visual acuity was 6/5 on the right and 3/60 on the left. Slit lamp examination showed bilateral panuveitis (inflammation in anterior and posterior segment). Her parotid glands were bilaterally enlarged and two small volume cervical nodes were palpable on the right. A cardiac, respiratory, neurological, skin, and joint examination was unremarkable. A recording of her vital signs included: respiratory rate 16 breaths/min, peripheral capillary oxygen saturation 99% on air, and temperature 36.8°C.

The results of a full blood count, electrolytes, liver function tests, erythrocyte sedimentation rate, C reactive protein, thyroid stimulating hormone, glucose, lipids, and bone profile were available from her GP and were all within normal ranges. A Paul Bunnell test was negative. Chest radiography was also performed (fig 1).

Questions

  • 1. What abnormality does the chest radiograph show?

  • 2. What are the differential diagnoses and the most likely diagnosis?

  • 3. How would you investigate this patient further to establish the diagnosis?

  • 4. How would you manage this patient?

Answers

1. What abnormality does the chest radiograph show?

Short answer

Bilateral hilar lymphadenopathy.

Discussion

The main abnormality in this plain film chest radiograph is symmetrical bilateral hilar lymphadenopathy (fig 2). Hyperinflation of the otherwise clear lung fields is also seen.

Fig 2 Chest radiograph showing bilateral …

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