Image Challenge

Q: A 13-year-old girl presented with new onset blurry vision in the left eye associated with
painful eye movements. Three weeks earlier, weakness and paresthesias had developed in
her left leg that spontaneously resolved. When a light was swung from the normal right eye
(Panel A) to the affected left eye, the left pupil dilated (Panel B) – a finding known as a
relative afferent pupillary defect. Fundoscopic examination of both eyes was normal.
Examination of the brain and whole spine by means of magnetic resonance imaging showed
multiple, oblong hyperintense lesions on T2-weighted images. What is the most likely
etiology?

1. Acute disseminated encephalomyelitis

2. Leber hereditary optic neuropathy
3. Mononeuritis multiplex
4. Multiple sclerosis
5. Retinal detachment
 Image Challenge

Q: A 13-year-old girl presented with new onset blurry vision in the left eye associated with
painful eye movements. Three weeks earlier, weakness and paresthesias had developed in
her left leg that spontaneously resolved. When a light was swung from the normal right eye
(Panel A) to the affected left eye, the left pupil dilated (Panel B) – a finding known as a
relative afferent pupillary defect. Fundoscopic examination of both eyes was normal.
Examination of the brain and whole spine by means of magnetic resonance imaging showed
multiple, oblong hyperintense lesions on T2-weighted images. What is the most likely
etiology?

Answer:

Multiple sclerosis

The correct answer is multiple sclerosis. Serum tests for aquaporin-4 and myelin
oligodendrocyte glycoprotein antibodies were negative. Oligoclonal bands were present in the
cerebrospinal fluid. Symptoms resolved after the initiation of steroids followed by
maintenance therapy with interferon beta-1a.