PMC6010661_01
Mid-venous phase fluorescein angiogram showing perivascular leakage in both eyes (red arrows), consistent with retinal vasculitis, and leakage from the nasal optic disc in both eyes (yellow arrows), suggestive of an inflammatory process. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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Fundal examination showed bilateral vitritis, and multiple intra-retinal hemorrhages with vascular sheathing and leakage on fluorescein angiography (Fig. 1), consistent with retinal vasculitis.
Representative slice of MRI brain: Axial images through the medulla and pons demonstrate abnormal signal intensity in the left lateral medulla (2A, blue arrow) and bilateral pons (2B, blue arrows) consistent with acute infarct. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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Magnetic Resonance Imaging (MRI) of the brain showed an area of restricted signal intensity in the left lateral medulla (Fig. 2A) with ischemic changes also noted along the left and right sides of the mid pons (Fig. 2B).
Representative slice of CT chest: Subcarinal and hilar lymphadenopathy (blue arrows); peribronchovascular micronodules predominantly affecting the upper lobes (green arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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CT of the chest showed intrathoracic lymphadenopathy with peri-bronchovascular micronodules in the upper lobes, consistent with sarcoidosis (representative slice, Fig. 3).
(A) Right lacrimal gland biopsy, Hematoxylin and Eosin (H&E) Stain, 100x; (B) Renal Biopsy, Hematoxylin and Eosin (H&E) Stain, 100x. Both show granulomas (black arrows) composed of tightly-packed histiocytes with multinucleate forms, and a surrounding chronic inflammatory infiltrate.
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A lacrimal gland biopsy showed non-caseating granulomas (Fig. 4A) with negative microbiology stains. On recent follow up the patient was noted to have deteriorating kidney function, which led to a renal biopsy that showed non-caseating granulomatous infiltration with negative microbiology stains (Fig. 4B).