A 13-Year-Old boy with Visual Changes after renal transplant Presentation of Case A 13-year-old boy was admitted to Apollo

hospital in Nephrology department becau se of blurring with occasional obscuration of vision in both eyes for one week . He also had associated progressive decreased perception of color .He had mild nonspecific intermittent headaches for last 3 months. He had no history of eye pain, ptosis and diplopia .He had no associated fever , neck stiffness, skin r ashes , arthralgia /arthritis or any other systemic or neurological symptoms . he had no H/O Two day before admission, the patient had two episodes of genera lize He had no history of drug abuse or any recent travel . Kidney transplantation had been performed 5 year earlier because of renal fa ilure possibly due to CGN. Preoperative workup revealed hepatitis C virus infect ion. Tacrolimus, azathioprine, furosemide, spironolactone, and course of cortico steroids were administered postoperatively. The immediate postoperative course w as uneventful for one and half year. After that he developed acute on chronic g raft rejection requiring hemodialysis for last two year. The patient had histor y of repeated hospital admission due to seizure. He was the second child of his parents. There was no family history of note. . His medications included prednisone (60 mg daily), esomeprazole, trimethoprim sulf amethoxazole, epoetin alfa, iron, multivitamins, and calcium. On admission, the blood pressure was 140/87 mm Hg, pulse 90 beats per minute,afe brile, respirations were 20 breaths per minute, with the oxygen saturation 99% w hile the patient was breathing ambient air.neurological examination revealed nor mal cognation. Both pupils measured 2 mm in diameter euually reacting, no ptosis or opthalmoplegia, visual acuity was 6/12, fundoscopy revealed no evidence of p apilloedema. He could distinguish between light and dark and could discern count ing fingers with his both eye. His face appeared symmetrical, and the results of the remainder of the neurological examination were normal. Laboratory Investigation revealed normal CBC, ANA, Serum iron, total iron bindin g capacity, serum electrolytes, serum calcium, serum phosphate, serum vitamin B1 2 and TSH.. Serum Phenytoin level was slightly above normal limit and Serum ferr itin was very high (>1650 ng/ml). IgM for CMV was negative. On the second hospital day neurology consultation was sought and advised for MRI scan brain , MRI scan of orbit, CSF study and ophthalmology re-evaluation. Dex amethasone was stoped and actazolamide started empirically in view of possibilit y of pseudotumour cerebrae. On the third hospital day, a lumbar puncture revealed an opening pressure of 15 mm of H2O Laboratory test results are with in normal limit. Ophthalmology reval uation revealed no chage visual acuity, permetry showed enlagement of b???????? ???????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????????????????