BACKGROUND: This case report documents a case of malignant pheochromocytoma manifested as vision changes with lung metastasis and recurrence.
METHODS: A 10-year-old Han Chinese girl presented with vision changes and was eventually diagnosed with pheochromocytoma by contrast-enhanced computed tomography, urine vanillylmandelic acid. After medication for hypertension and surgery, clinical symptoms disappeared. Malignant pheochromocytoma with lung metastasis was confirmed histologically using the Pheochromocytoma of the Adrenal Gland Scaled Score scoring system and genetically with succinate dehydrogenase complex iron sulfur subunit B mutation, and 3 months later, unplanned surgery was performed because of the high risks and signs of recurrence. She is asymptomatic as of the writing of this case report. Our patient\'s case highlights the importance of considering a diagnosis of malignant pheochromocytoma, and long-term follow-up for possible recurrence.
CONCLUSIONS: Although there are well-recognized classic clinical manifestations associated with pheochromocytoma, atypical presentation, such as vision changes in children, should be considered. In addition, malignant pheochromocytoma children with a high Pheochromocytoma of the Adrenal Gland Scaled Score and succinate dehydrogenase complex iron sulfur subunit B mutation require a long-term follow-up or even unplanned surgery because of the higher risk of recurrence.

Vitamin A deficiency (VAD) is common in developing countries but rare in resource-rich countries. In developed countries, malabsorption and behavioral issues are more common reasons for VAD. The current case is an example of a healthy child who developed ocular symptoms due to vitamin A deficiency in the setting of cultural influences and emotional stressors.

BACKGROUND: Emergency physicians frequently evaluate patients with vision changes. The differential for this chief symptom is broad. We present a unique cause of a fixed scotoma that started while the patient was running sprints.
METHODS: The patient described a bright central scotoma that later became a dark oblique line across her central vision. This painless defect moved predictably with eye movements. Ocular ultrasonography was performed and revealed a well-demarcated hyperechoic lesion in the posterior segment of the right eye. There was no similar lesion found in her left eye. In consultation with ophthalmology, the patient\'s history and examination were consistent with valsalva retinopathy. To our knowledge, this is only the second published case of valsalva retinopathy/premacular hemorrhage identified on ocular ultrasonography in emergency medicine literature. In this article, we further expand on management and provide correlating fundoscopic images. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently evaluate patients with visual changes. Valsalva retinopathy is a rare cause of a visual scotoma that can be diagnosed through history and ultrasound. It often resolves over weeks to months without intervention. However, it does require urgent ophthalmologic evaluation to rule out peripheral retinal tears, which may require laser retinopexy or surgical management.

Non-Hodgkin lymphoma (NHL) is a hematological malignancy that can sometimes originate from the nasal cavities and paranasal sinuses. Patients who present with these tumors typically report sinonasal symptoms. However, a diagnostic challenge can arise when a patient\'s primary complaints include unique complex symptoms limited to the contralateral side of the tumor. This report describes the case of an 83-year-old man who presented to our center with a left-sided mass and right-sided proptosis with vision loss. After a nasal biopsy was taken, the patient was referred to the ophthalmology department to diagnose the cause of his ocular symptoms, which were not believed to be related to the mass. When biopsy results later returned as diffuse large B-cell lymphoma (DLBCL), an emergent repeat biopsy following lymphoma protocol was performed to confirm the diagnosis. A CT scan of the head and orbits showed generalized enlargement of the right optic nerve and extraocular muscles, and a positron emission tomography (PET) scan showed increased 18F-fluorodeoxyglucose (FDG) uptake in the right ethmoid sinus and orbit. The left-sided mass and right-sided symptoms resolved simultaneously with chemotherapy. This is the first documented case of a sinonasal mass causing ocular symptoms exclusively on the contralateral side. The presented diagnostic challenge highlights the importance of thorough investigations.