Joe & Jerry Flew the Coop

A previously healthy 13-year-old girl presented to a local hospital with fever and myalgia, followed one day later by lethargy and vision loss. Past medical history was significant only for acne, for which she had been treated with doxycycline 40 mg/day intermittently starting 2 months prior to symptom onset. In the emergency department, the patient was difficult to arouse. Within 24 hours of onset, arousal level spontaneously returned to normal, but vision was light perception in both eyes. Based on fundus examination, she was given a presumptive diagnosis of neuroretinitis and transferred to our hospital. On our examination, visual acuity was light perception only in both eyes. Pupils measured 7mm in dim illumination and constricted moderately to direct light. Ophthalmoscopy in both eyes revealed nearly confluent, sharp-bordered ischemic retinal white patches in the posterior pole. Optical coherence tomography (OCT) showed inner retinal thickening and hyperreflectivity. Fluorescein angiography (FA) revealed occlusion of multiple small arterioles in the areas of retinal whitening. A wide-field FA confirmed multifocal arteriolar occlusions posteriorly with minimal late leakage and no retinal vascular abnormalities in the periphery. Brain MRI demonstrated symmetric T2 hyperintensities on FLAIR images in the region in both LGBs, and in the cerebellar vermis and dorsal midbrain. T2- weighted gradient echo images showed hypointensities with blooming in the LGBs, indicative of hemorrhage. These lesions showed restricted diffusion. ESR was 46, CRP was 0.1 and the following labs were negative: cardiolipin antibody, anti-DsDNA, anti-SSb/anti-La, anti-Sm, anti-RNP, antiscleroderma, anti-Jol, chromatin, ribosomal protein and centromere B. An additional test was performed