The patient

A 4-year-old boy presented to the hospital with fever, fatigue and weakness. He also complained of blurry vision. He had recently had nose bleeds and oral bleeding. A complete blood count showed pancytopenia, as well as blasts on his peripheral smear.

A bone marrow aspiration and biopsy were performed. He was diagnosed with B-cell acute lymphoblastic leukemia and was started on chemotherapy. Due to worsening visual acuity, a brain MRI was performed. It revealed a large arachnoid cyst in addition to bilateral retinal and vitreous hemorrhages. Ophthalmic exam demonstrated papilledema of the left optic nerve, as well as bilateral retinal hemorrhages.

The challenge

The large arachnoid cyst was causing midline shift and mass effect, and may also have contributed to the patient’s ocular findings. Eventually, it would have caused increased intracranial pressure and even possible neurological symptoms.

Before shunt

Esther E. Knapp, M.D.
Pediatric hematologist/oncologist
Norton Children’s Cancer Institute
Affiliated with the UofL School of Medicine

Mustafa Barbour, M.D.
Pediatric hematologist/oncologist
Norton Children’s Cancer Institute
Affiliated with the UofL School of Medicine

Kingal Virshni, M.D.
Pediatric radiologist
Norton Children’s Radiology
Affiliated with the UofL School of Medicine

Thomas M. Moriarty, M.D.
Pediatric neurosurgeon
Norton Children’s Neuroscience Institute
Affiliated with the UofL School of Medicine

Charles C. Barr, M.D.
Ophthalmologist
University of Louisville Physicians – Eye Specialists

The solution

A cyst-peritoneal shunt was placed by Thomas M. Moriarty, M.D.. In addition, the patient underwent eye surgery, performed by ophthalmologist Charles C. Barr, M.D., to alleviate his vitreous hemorrhages. After surgery his vision significantly improved.

After shunt

The result

The patient’s vision improved significantly after his eye surgeries. He was able to recognize medical staff and watch videos without bringing the tablet directly to his face. After his shunt was placed, he was able to continue with routine lumbar punctures with intrathecal chemotherapy in order to treat his leukemia.

Treatment and results may not be representative of all similar cases.