Acute onset of bilateral mydriasis, headache, and vomiting: a challenging diagnosis

Bilateral fixed mydriasis is a rare condition that can arise from a variety of causes (neurological, pharmacological, toxic or metabolic, para-infectious/autoimmune conditions, and traumatic injuries). We report a 65-year-old woman presenting to the emergency department with bilateral mydriasis and complaining of acute severe headache associated with blurry vision, photophobia, vomiting, and a recent history of fever with respiratory symptoms. All preliminary medical investigations aimed at identifying possible causes of endocranial hypertension as well as intracranial lesions or expansive processes, while focusing on findings consistent with meningoencephalitis. The diagnosis of acute bilateral angle-closure glaucoma was established through a wide range of radiological and laboratory exams, and with the help of different consultants. This unusual case highlights two interesting aspects: the importance of a multidisciplinary diagnostic work-up for challenging clinical presentations, and the critical relevance of a re-evaluation diagnostic strategy to avoid clinical mistakes.