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Endgames Picture Quiz

Blurred vision and epistaxis

BMJ 2014; 348 doi: (Published 20 January 2014) Cite this as: BMJ 2014;348:g91
  1. Kate Shirley, specialist trainee year 2, ophthalmology1,
  2. Feargal P McNicholl, consultant haematologist2
  1. 1Department of Ophthalmology, Belfast Health and Social Care Trust, Belfast BT12 6BA, UK
  2. 2Department of Haematology, Altnagelvin Hospital, Altnagelvin, Londonderry, UK
  1. Correspondence to: K Shirley

A 34 year old man presented with a three month history of blurred vision. He also mentioned nose bleeds, worsening headaches, and pain in the right knee. He had experienced some weight loss and tiredness but had been previously healthy and took no drugs on a regular basis.

His general practitioner carried out full blood tests in light of the recurrent epistaxis: haemoglobin was 127 g/L (reference range 130-180), platelets 111×109/L (140-400), white cell count 275×109/L (3.6-11.0), neutrophils 107×109/L (1.8-7.5), lymphocytes 11×109/L (1.0-4.0), monocytes 5.52×109/L (0.2-0.8), eosinophils 8×109/L (0.1-0.4), and basophils 0×109/L (0.02-0.1). He was subsequently admitted to hospital for investigations. On admission he was apyrexic and his blood pressure was 130/76 mm Hg. His spleen was not palpable, but ultrasonography of his abdomen showed splenomegaly of 16 cm. His coagulation screen was normal: prothrombin time 12.4 s (11-14), activated partial thromboplastin time 27.7 s (26-39), and fibrinogen 18 µmol/L (4.4-11.8). Renal function was slightly impaired, with a creatinine concentration of 136 µmol/L (58-110) and an estimated glomerular filtration rate of 52 mL/min/1.73m2. Uric acid was increased, at 510 µmol/L (200-430). The lactate dehydrogenase concentration was noticeably increased, at 2458 IU/L (105-133), the vitamin B12 level was increased, at >1500 pmol/L (110-664), and C reactive protein was 4.2 mg/L (<5).

Visual acuity was 6/9 in the right eye and 6/24 in the left eye. Fundal examination revealed bilateral changes, as shown in the fundal photograph of the left eye (fig 1).

Fig 1 Fundal photograph of left eye


  • 1 What is the likely diagnosis based on the history and investigations?

  • 2 How would you confirm your diagnosis?

  • 3 What does the fundal photograph show?

  • 4 What is your differential diagnosis for the fundal appearance of this …

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