A 20 year woman from Sierra Leone, presented with a three week history of pain and blurred vision in her left eye. She reported feeling unwell for one month with malaise, anorexia, weight loss, and night sweats. Her general practitioner had recently diagnosed asthma as she had been short of breath on exertion, and she had a dry cough. She was a non-smoker on no other medication.

On examination she was thin, alert, and apyrexial. She had no rash or lymphadenopathy. Her respiratory rate was 20 breaths/min, and her trachea was central. On auscultation she had inspiratory stridor, with a peak expiratory flow rate of 240 l/min, and oxygen saturations on air that fell from 94% to 78% on exertion. Cardiovascular and abdominal examinations were unremarkable except for a tattoo on her abdomen. Visual acuity was light-dark discrimination in the left and 6/6 in the right. Colour perception was maintained, and fundoscopy was normal. Other cranial nerves were normal. Peripheral nervous system examination revealed normal tone, power and reflexes, with flexor plantar responses. There was no sensory disturbance.

Investigations showed a haemoglobin concentration of 136 g/l, platelet count 325 × 10⁹/l, and white cell count 6.7 × 10⁹/l (neutrophils 5.2, lymphocytes 0.71). Urea and electrolytes, liver function tests, and arterial blood gases were within normal limits. Total protein was 88 g/l, albumin 41 g/l, and erythrocyte sedimentation rate of 72 mm/hour. Lumbar puncture showed an opening pressure of 13 cm, white cell count <5/mm, protein 164 mg/l, glucose 4.7 mmol/l (plasma glucose 9.3 mmol/l); no organisms were seen on Gram stain.

Chest radiography and magnetic resonance imaging (MRI) of the orbit are shown in figs 1 and2.

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Figure 1

Chest radiograph.

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Figure 2

MRI scan.