Chief Complaint: “I’ve been having severe itching and blurry vision in both of my eyes.”

History of Present Illness:
A 38-year-old man presents with complaints of intense itching and small, raised bumps on his skin, primarily on his upper body. He also reports experiencing blurred vision for the past few weeks, especially in the mornings. The patient mentions that these symptoms started gradually and have been worsening over the last 2-3 months. He recalls frequent visits to a rural area near a fast-flowing river during the past year, where he spent a significant amount of time working outdoors. He remembers being bitten by small insects during his time there.

The patient denies any fever, joint pain, or weight loss. However, he is concerned because his vision is becoming progressively worse, especially at night.

Physical Examination:

• Multiple pruritic, subcutaneous nodules along the back and shoulders
• Erythematous, slightly raised skin lesions in areas of high exposure
• No obvious signs of ocular inflammation, but decreased visual acuity with cloudy corneas and a slit-lamp exam revealing microfilariae in the anterior chamber of both eyes
• No lymphadenopathy or systemic signs of infection

Diagnosis:
Based on the clinical findings of pruritic nodules and visual impairment, along with a history of river exposure, onchocerciasis (river blindness) is suspected. This condition is caused by Onchocerca volvulus, transmitted by the bite of blackflies found near rivers. The adult worms form subcutaneous nodules, and microfilariae can migrate to the eyes, causing blindness.

Management Plan:

• Antiparasitic treatment: Ivermectin to kill microfilariae and reduce symptoms
• Ocular treatment: Referral to an ophthalmologist for eye care, as visual impairment may require more specialized management
• Symptomatic relief: Topical corticosteroids for skin inflammation and antihistamines for itching
• Patient education:
  • Avoiding areas with high blackfly populations
  • Importance of completing the full course of ivermectin treatment to reduce transmission

The patient is scheduled for follow-up to monitor the effectiveness of the treatment and manage ocular symptoms.