Case presentation of a young male with suspicion of Zieve Syndrome.

1. MODERATORS
PROF. SAIYID NASIR ASKARI
DR. ABDUL WARIS
PRESENTER
DR. ARMAAN AHMED
DATE : 21/1/2019

2. Patient particulars
 Name : xyz
 Age/Gender : 23 yrs/male.
 R/O : Aligarh

3. Chief Complaints
.
 Diminution of vision in both eyes (OS>OD)
- 15 days history.

4. History of present illness:
 The patient was apparently well when he noticed
diminution of vision in both eyes.
 It was sudden and painless in nature.

5. Negative History
No history of :
 Discharge
 Spectacle usage
 Trauma
 Ocular surgery
 Drug intake
 Itching
 Lymphadenopathy
 Radiation exposure
 Weight loss

6. Past History
 Jaundice – one month back for which he took treatment
for 15 days in Kolkata.
 During travelling to Aligarh he had worsening of
symptoms such as, vomiting, loss of appetite, weakness
and fever.
 For these complaints, he consulted a private practitioner
and investigations revealed anaemia and was advised for
blood transfusion.
 He was transfused with 2 units of blood on the 28th and
29th of December (blood group : O negative).

7. Family History
 No history of similar complaints in any of the
family members.

8. Personal History
 Diet : Vegetarian
 Appetite : Normal
 Sleep : Adequate
 Bowel : Normal & Regular
 Bladder : Normal & Regular
 Addictions : alcohol consumption one beer can
daily.

9. General Examination
 Patient is of average built and nutrition, well
oriented to time, place & person, neither dyspneic
nor cyanosed.
 Vitals:
PR - 84/min
RR - 18/min
Temp - Afebrile
BP - 136/82 mmHg
Wt. - 80 kg

10. Systemic Examination
 CVS : WNL
 CNS : WNL
 Respiratory system : WNL
 Abdomen Examination :
Inspection-WNL
Palpation – hepatomegaly noted.
Percussion – WNL
Auscultation- Normal bowel sounds heard.

11. Investigations
27/12/18
 Total bilirubin : 2.9 mg/dl (0.1 – 1.2)
 Hemoglobin : 3.8 g/dl
 Total leukocyte count : 7,900 WBC’s/microlitre
blood (4,000-11,000)
 Platelet : 70,000 per microlitre of
blood (1,50,000-4,50,000)
 Mean Corpuscular Volume (MCV) : 110.68 ( 80 – 96 fl per
red cell)
 Red blood cells: Microcytic and Macrocytic seen with tear drop
cells and few fragmented RBC’s.

12. Ocular Examination
• Head Posture : Normal
• Forehead : Normal
• Facial Symmetry : affected with
• Eyebrows (BE) : Normal
• Eyelids (BE) : Normal
• Ocular Movements (BE) : Full in all gazes

14. Visual Acuity & IOP
 VA - RE: plain 6/12
LE: plain 6/60
 IOP(NCT)- RE: 14mmHg
LE: 15mmHg
 CCT - RE:522
LE:530

15. Slit Lamp Examination (RE)
RIGHT EYE
EYELIDS Normal
CONJUNCTIVA Normal
CORNEA Clear
ANTERIOR CHAMBER Normal depth & quiet
PUPIL Normal size, Normal
reaction
IRIS Normal color & pattern
LENS Clear
Digital tension Normal

16. Slit Lamp Examination (LE)
LEFT EYE
EYELIDS Normal
CONJUNCTIVA Normal
CORNEA clear
ANTERIOR
CHAMBER
Cell
PUPIL Dilated under mydriatic and
non reacting to light
IRIS Normal color & pattern
LENS Clear
Digital tension Normal

17. Fundus Examination (RE)
 Red glow: present
 Media clear
 Disc
o Size normal
o Shape normal
o Color Normal
o Margins Normal
o C:D ratio : 0.3
 B/G: multiple pre retinal
hemorrhages, superficial and
deep hemorrhages.
 B/V: WNL
 Macula : boat shaped hemorrhage approx. 1/4th DD size involving
fovea is present.

18. Fundus Examination (LE)
 Red glow - present
 Media clear
 Disc
o Size normal
o Shape normal
o Color normal
o Margins intact
o C/D ratio 0.3
 B/G – multiple superficial
and deep hemorrhages;
 B/V - normal
 Macula – large pre retinal hemorrhage approx. 1DD, irregular
shape involving fovea present.

19. Provisional Diagnosis
 Hemorrhagic Retinopathy (BE) with Hemolytic anaemia.

20. Differential Diagnosis :
Diagnosis Points in favour Points against
Hemolytic anaemia
post blood
transfusion
Increased bilirubin,
fragmented RBC’s,
Increased LDH
Coomb’s test result
awaited.
Post Malaria
infection
History of fever,
Anaemia
Absent roth spots,
Post EBV infection History of fatigue,
jaundice,
Further testing
needed.
Alcohol misuse/
Zieve’s syndrome
History of a can of
beer intake daily,
increased MCV,
macrocytosis
Usually disease
occurs on intake of
60 – 80g/d over 5-
8 years

21. Investigations
12/01/19
 Random Blood sugar : 105 mg/dl ( 79-160)
 BUN : 10mg/dl (7-38 )
 Creatinine : 0.71mg/dl ( 0.6-1.2 )
 Alkaline phosphatase : 84 U/l ( 38-126 )
 ALT : 25 U/l ( 13-72 )
 AST : 18 U/l ( 15-59 )
 Total bilirubin : 1mg/dl ( 0.2-1.2 )
 ESR : 30 mm/hour ( 0 – 22 )
 Direct : 0.2 mg/dl ( 0.0 – 0.2 )
 Indirect : 0.8 mg/dl ( 0.0 – 1.1 )

22.  Blood Picture :
Red blood cells show a mixture of microcytes, normocytes and elliptocytes having
normochromia and mild hypochromia. No hemoparasite, toxic granules or immmature
cells seen.
Total leucocyte count : Normal for age
Platelet count : adequate by smear.
 Bleeding time : 1min 45 sec ( 2 – 7 mins )
 Clotting time : 4 min 45 sec ( 4 – 15 mins )
 Lactate dehydrogenase : 522 U/L ( 230 – 460 U/L)
 Anti Nuclear Antibody ( ANA ) : negative

23.  Ultrasound Abdomen :
Hepatomegaly ( approx 16.5 cm )
Pancreas – normal
Gall bladder – normal
Spleen – normal
Kidneys - normal

24. Treatment
 Patient was advised :
- Eye drop Nepafenac (BE) x tds
- Tab. Celin x 1tab x TDS
- Review after 1 week in Retina Clinic.

25. 17/1/2019
 BCVA - RE: +0.5 DS 6/12
LE: +0.5 DS 6/36;
 IOP(NCT) - RE: 15mmHg
LE: 14mmHg
 CCT - RE: 524 µm
LE: 528 µm

26. FUNDUS PICTURE (OD)

27. FUNDUS PICTURE (OS)

28. THANK YOU