Clinical presentation

A 56-year old white woman was referred for ophthalmic assessment of acute bilateral painful visual loss over 3 weeks accompanied by malaise and fever.

During the preceding year, she had had intermittent retro-orbital headache, nausea, low-grade fever and lethargy. She had been living with her son who had been treated for pulmonary tuberculosis on his return from Central America 18 months earlier. Therefore, after she failed to respond to a course of oral antibiotics for presumed sinusitis, investigations to rule out tuberculous meningitis were performed. A grade 3 response to a Heaf test was noted in the presence of a BCG vaccine scar. However, blood and cerebral spinal fluid cultures were negative and results of the chest x-ray, computed tomography (CT) and magnetic resonance imaging of the head were all normal. Raised C-reactive protein level of 75 mg/l and erythrocyte sedimentation rate of 99 mm/h lead to a suspicion of temporal arteritis. Treatment with oral prednisolone led to resolution of her headache and normalisation of her erythrocyte sedimentation rate. However, steroids were tapered off after a normal temporal artery biopsy. Four months later, she developed a dry cough and headache associated with malaise. A thoracic CT scan showed some minor focal areas of inflammation. Treatment with clarythromycin for presumed atypical pneumonia resulted in a temporary improvement in symptoms.

The only other significant history was of cutaneous melanoma that had been completely excised 8 years previously.

Thoracic CT and magnetic resonance imaging scans now demonstrated a solitary nodule …