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Vol 130, No 12, December 2012

Archives Clinical Challenge: You Make the Diagnosis

Transient Monocular Vision Loss in a 56-Year-Old Man


A 56-year-old man with a history of asthma had shortness of breath and 3 episodes of transient monocular vision loss, which he described as a “web that gradually coalesced into a white veil.” Each episode lasted approximately 2 minutes before spontaneously resolving. Other symptoms included cough, headaches, and mild fever for 2 weeks. Examination revealed hypoxia, wheezing, bibasilar lung rales, atrial fibrillation, and scattered erythematous skin plaques and macules. His blood leukocyte count was 15 200/μL (to convert to ×109 per liter, multiply by 0.001), his erythrocyte sedimentation rate was 38 mm/hr, and his C-reactive protein level was 68 mg/L (to convert to nanomoles per liter, multiply by 9.524). Respiratory decompensation prompted treatment with broad-spectrum intraventous antibiotics. Ophthalmic examination findings were normal. A temporal artery biopsy was performed, revealing active, circumferential arteritis with numerous eosinophils, mononuclear leukocytes, and karyorrhectic debris concentrated in the intima and adventitia but also involving the media (Figure). Intimal damage was marked with loss of elastica in areas of intense intimal inflammation where mural thrombi containing numerous eosinophils deposited along the lumen of the vessel were present. Focal fibrinoid necrosis was seen in a branch artery.

What is your diagnosis?

Image of figure 1

Temporal arterial transmural leukocytic infiltrate with chiefly intimal damage (hematoxylin-eosin, original magnification x200).

Please e-mail your diagnosis to ophthquiz@ama-assn.org. You must include your full name, mailing address, and institutional affiliation in the initial e-mail to be eligible to enter the quiz. The first correct respondent will be recognized in the print journal and on our website and will receive a 1-year complimentary online subscription to Archives of Ophthalmology. Because of the volume of responses we are able to respond to the first person with the correct answer only.

For a complete presentation of this case and an in-depth discussion of the entity, please see next month's edition of JAMA Ophthalmology.

The correct answer to our November challenge was white dot fovea.

For a complete discussion of this case, see the Small Case Series section in the December Archives (Witkin AJ, London NJS, Wender JD, Fu A, Garg SJ, Regillo CD. Spectral-domain optical coherence tomography of white dot fovea. Arch Ophthalmol. 2012;130[12]:1603-1605).