 All right, so I'm going to present a case on homoptysis and associated vision loss. So this is a 13-year-old African-American girl who has a history of chronic homoptysis and resulting hypoxia and anemia. And upon admission, she was found to have profound vision loss, and therefore, ophthalmology was involved. So her past medical history, she was a very healthy young girl until about July of 2014 when she developed homoptysis while she was playing basketball. Prior to this, she had never been admitted, never been on any medications. She had repeat admissions over the next 20 months at various institutions in Las Vegas, and she was treated with several high-dose steroid pulses followed by oral tapers. And then she also received two doses of cytoxan, and that was in July of this last year, and then that was discontinued. She had a working diagnosis of idiopathic pulmonary hemociderosis. So her ophthalmic history, in about September of 2015, she had a very severe episode of homoptysis. And her hemoglobin was reported to be a 2 by her grandmother. However, upon reviewing her records, it looks like her lowest hemoglobin was about a 5.9. She reports that her vision became very blurry after this and that she had associated right eye pain. And then she was seen by ophthalmology in Las Vegas. We have only some of those records. And her vision was reported to be count fingers at one foot in her right eye and 20, 30 in her left eye. There was no APD. And she was referred to retina because she was felt to have some sort of macular irregularity, though her Mac OCT was normal. And we don't have the records from that retina specialist. And then in January of this last year, she was seen again. Her vision had worsened to light perception in the right eye and 20, 50 vision in the left eye. Again, there was not an APD, but she was referred to neuroophthalmology in Las Vegas. And again, we don't have those records. So in February of this year, she completed a six month course of steroids, a very slow taper that started out 80 milligrams twice daily. And then the first week of March, she noticed a decrease in her vision again. She was seen by the general ophthalmologist who noted that she had no light perception in her right eye and 20, 60 vision in her left eye. It was the first time an APD was noted, and she was sent to get some imaging. But then just about a week or two later, she again developed some very, very severe hemoptysis, hypoxia, and increased oxygen needs, and therefore was transferred from the ICU in Las Vegas to the PICU here at Primary Children's. So her initial examination by ophthalmology the day after admission was no light perception in the right eye, 20, 25 vision in the left. She was unable to see any color plates with the right eye, and she had got four out of eight Isha Harrah plates in the left eye. Her right eye constricted to consensual light. Her left eye was sluggish, but constricted to both direct and consensual light, and there was a very large APD. Her extraocular movements were full and her IOP was normal. Her orbit slids and lashes were normal and her conjunctiva and sclera were white and quiet. Her corneas were clear bilaterally. Her anterior chambers were deep and quiet. Her lenses were clear, and her fundoscopic exam showed bilateral pallor of her optic nerves, but her macular vessels and periphery were normal. So her outside workup at this time had included an ESR and a CRP, which were normal, but it was when she was on 80 of prednisone twice daily. Her CMPs have been normal. She's had low hemoglobin for basically 20 months, low MCV, but her iron studies have been normal. Her autoimmune workup thus far, oops. Her autoimmune workup thus far has been really unremarkable. She did have a lung biopsy done. There was some concern, could this be vasculitis? However, it just showed some bronchiolitis and mild lymphoid hyperplasia. However, again, she was on about two months of high-dose steroids when this was done. She also had MRA head and neck and MRV of her head and MRI brain with and without contrast. This was done in December of last year, so about four months prior to presentation. And in Las Vegas, these were all read as normal. They were over read at primary children's and also read to be completely normal. So our differential diagnosis at this time, we thought most likely this sounded like a posterior ischemic optic neuropathy given that her symptoms were right after she had that severe episode of hemoptysis and very low hemoglobin. However, we also considered optic neuritis considering that there was never an MRI of her orbits done and that it could have been done at a time at which this was quiet. And within that category, we considered MS, NMO, sarcoid, infectious and vasculitis to be most likely. So she had some repeat imaging done. This time it was definitely not normal. You can see that there's some bilateral white matter lesions on both sides and a very large one in the left frontal lobe. And here you can see her right optic nerve is lit up and she has optic neuritis. And you can see that goes basically all the way from the globe and into the chiasm. She also had lesions in her cervical spine and in her thoracic spine. And then on 3, 22, 16, her C. Inca came back positive. And as you may know, that is often positive in granulomatosis, polyangitis, previously known as Wegner's. However, usually both, sorry, usually both the MPO and PR3 are abnormal and usually there'll be some signs of vasculitis. A CT, angio-necbrane and chest was done, all which were completely normal. So it just didn't seem like this was a GPA. So we brought her over to clinic the next day and as you can see, she had bilateral optic nerve pallor and strangely she actually had more cupping on the left eye compared to the right even though it was the right eye that had the poor vision. And yet that was confirmed with the RNFL with the global thinning. There was some remaining neurofiber layer inferiorly and nasally in the right eye. And then her visual field in the left eye showed some temporal defect and she could not, she was no light perceptions so we didn't get one of the right eye. So her medical course, she did develop transverse myelitis the next day after neurophthalmology clinic which started with leg pain and then she developed numbness of her feet and toes and then it ascended and she actually developed paralysis of both her legs. Then she had a lung biopsy done due to her positive C. anka and she was off prednisone for a month at that time so we felt that maybe it would show something new. And right after the biopsy was done she was started on high dose prednisone. So then the next day we got some big answers some important answers. Her NMO came back positive, had been drawn twice and both of them were positive. Her high dose steroids were continued and she started on plasmapheresis. A few days later her wedge biopsies came back and they were consistent with vasculitis and there were no granulomacine so that kind of did not completely rule out but felt like the sarcoid was less likely given that there were no granulomacine. So basically at this point we felt that there were two diagnoses one being neuromyelitis optica and the other being vasculitis. So after she received about four treatments of plasmapheresis her strength started to increase. She became more stable from a pulmonary standpoint and she had some subjective improvement of vision out of her right eye. So on her follow-up neuropathic exam her vision improved from no light perception to hand motion. Her left eye vision did not improve, it was still 2050. She had a 2.4 log APD in the right eye. Her extracurricular movements were full she was still having a little bit of pain with up gaze and her intracurricular pressures were normal. Her anterior chamber did show a few pigmented cells but was otherwise unremarkable and her fundus exam was unchanged. So her treatment plan was basically to get seven treatments of plasmapheresis and then a dose of IVIG. She was started on rituximab and will be on that for a long time and then she will have a very slow taper of her prednisone. She was discharged to UNLV Hospital over this last weekend and she'll be following up with us in about a month and if there were some potentially some insurance issues and some travel issues so she may be following up in Las Vegas. So that's that case. I'll have you hold your questions until we kind of go over the spectrum.