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Retinal Vasculitis Associated with Epstein-Barr Virus Infection in a Young Immunocompetent Patient

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Retinal Vasculitis Associated with Epstein-Barr Virus Infection in a Young Immunocompetent Patient case reports 2019; 5(2) https://doi.org/10.15446/cr.v5n2.78620 RETINAL VASCULITIS ASSOCIATED WITH EPSTEIN-BARR VIRUS INFECTION IN A YOUNG IMMUNOCOMPETENT PATIENT. FIRST COLOMBIAN CASE REPORT Keywords: Epstein-Barr Virus Infections; Retinal Vasculitis; Acyclovir. Palabras clave: Infecciones por virus de Epstein-Barr; Vasculitis retiniana; Aciclovir; Retinitis. Santiago Sánchez-Pardo Universidad Industrial de Santander - Faculty of Health - Department of Internal Medicine - Bucaramanga - Colombia. Julia Recalde-Reyes Universidad Nacional de Colombia - Bogotá Campus - Faculty of Medicine - Department of Internal Medicine - Bogotá D.C. - Colombia. Juan Pablo Osorio-Lombana Universidad Nacional de Colombia - Infectious Diseases Service - Bogotá D.C. - Colombia. Corresponding author Santiago Sánchez-Pardo. Department of Internal Medicine, Faculty of Health, Universidad Industrial de Santander. Bucaramanga. Colombia. E-mail: [email protected] Received: 21/03/2019 Accepted: 06/05/2019 case reports Vol. 5 No. 2: 139-46 140 RESUMEN ABSTRACT Introducción. La infección por virus de Epstein-Barr Introduction: Epstein - Barr virus (EBV) infection (VEB) suele ser asintomática y persiste durante is usually asymptomatic and persists throughout toda la vida. La afectación ocular es infrecuente, life. Eye involvement is rare, and even though y aunque existen informes de casos, ninguno de there are some case reports, none of them comes ellos proviene de Colombia o Latinoamérica. from Colombia or Latin America. Presentación del caso. Paciente masculino Case presentation: Immunocompetent young inmunocompetente con vasculitis retiniana unila- man with generalized unilateral retinal vasculitis, teral generalizada, con vasos sin sangre tempo- temporal and inferonasal bloodless vessels in rales e inferonasales en la periferia, hemorragias the periphery, intraretinal hemorrhages, intense intrarretinianas, vitritis intensa y desprendimiento vitritis and retinal detachment. Epstein-Barr virus de retina. La presencia de VEB se definió con presence was determined using a polymerase una técnica de reacción en cadena de la poli- chain reaction technique in vitreous humor. The merasa en humor vítreo. El paciente recuperó la patient recovered visual acuity with conventional agudeza visual con el tratamiento oral antiviral antiviral oral treatment. convencional. Discussion: Eye involvement associated with Discusión. La afectación ocular asociada con el Epstein-Barr virus is observed in immunocom- VEB se describe en pacientes inmunocompro- promised patients, especially with HIV infection, metidos, en especial con infección por virus de where retinal involvement may occur. This case inmunodeficiencia humana donde puede haber reports the presence of this pathology in an afectación retiniana. En este caso particular immunocompetent patient. se discute la presencia de esta patología en pacientes inmunocompetentes. Conclusions: Retinal vasculitis is a rare entity, frequently associated with immunocompromise. Conclusiones. La vasculitis retiniana es una There is no diagnostic algorithm for this disease entidad rara con mayor asociación a la inmuno- and eye involvement may be variable; there are no depresión. No existe un algoritmo de diagnóstico standard lines of treatment either. The evidence de esta enfermedad y la afectación ocular puede reported here explains the need for studies in ser variable; tampoco existen líneas estándar de selected patients showing visual acuity involve- tratamiento. La evidencia reportada en el presente ment without an established etiology. caso podría justificar estudios en pacientes se- leccionados que muestran un compromiso de la agudeza visual sin una etiología establecida. retinal vasculitis associated with epstein-barr virus infection INTRODUCTION systemic disease. Definitive evidence of EBV 141 with acute retinal necrosis or vasculitis is scarce Epstein-Barr virus (EBV) was described in 1964 and has few cases reported in the literature. in cell cultures from Burkitt lymphoma samples; (3-6) Retinitis is a cause of impaired visual however, infectious mononucleosis is the clinical acuity, which should lead to differential diag- syndrome most frequently associated with this nosis given its impact on patients with human infection. (1,2) immunodeficiency virus (HIV) infection. (3-6) EBV, or human herpesvirus type 4, belongs Based on the above, the objective of this to the Herpesviridae family, Gammaherpesviridae report is to present a case of retinitis by EBV subfamily, and is the prototype for the Lymphoc- in an immunocompetent young adult patient, ryptovirus genus. It has a double-stranded 172kb highlighting, on the one hand, that this pre- DNA encapsulated in a 100nm icosahedral sentation is rare in this population group and, capsid that protects genetic information, and on the other, the success of treatment with surrounds itself with a complex proteolipid en- Aciclovir despite the little evidence available velope. To date, only 2 types of this virus have in the literature. been identified: EBV-1 and EBV-2. (1,2) Its role as an infectious agent in eye pa- CASE PRESENTATION thologies is still little known, since 95% of the healthy population has positive antibody titers; it An 18-year-old male, high school student from is only observed in immunocompromised patients Bogotá D.C., Colombia, white, of a middle-income with rare severe ophthalmological involvement. household, was treated at a quaternary care Occasionally, conjunctivitis or uveitis may occur, hospital in December 2017 for symptoms charac- although some other herpesviruses, such as terized by loss of visual acuity and myodesopsia herpes simplex and varicella-zoster virus, may in the right eye, which appeared suddenly three cause retinal involvement with necrosis. (3-5) months earlier. Since the onset of symptoms until EBV has been ascribed several ophthal- the time of consultation, the man was empirically mological pathologies, including multifocal managed with Acyclovir at a dose of 400mg every choroiditis and, in the presence of systemic 12 hours with partial improvement of symptoms; infections, all segments of the eye are involved. the dose was adjusted to 400mg every 4 hours Ocular manifestations related to EBV infection by indication of the Infectious Diseases Service may range from oculoglandular syndrome to in December 2017. conjunctivitis, dry eye syndrome, keratitis, uveitis, In the initial ophthalmology evaluation, the choroiditis, retinitis, ophthalmoplegia, or papil- external eye examination was normal in both litis; specifically, conjunctivitis, dacryoadenitis, eyes; biomicroscopy showed clear cornea, epiescleritis, keratitis, and iritis are observed well-formed anterior chamber, round central in the anterior segment. Reported neurological pupil and normal iris in both eyes. Ocular pres- complications include papilledema and optic sure was 12 in both eyes, and the lens was neuritis. (5,6) transparent in both eyes. Retina and vitreous Retinal involvement is rare in cases of EBV body examination showed retinal detachment associated with infectious mononucleosis; with abundant subretinal hemorrhage in the however, a variety of presentations, including lower region and mild vitreous hemorrhage with retinochoroiditis, have been associated with macular involvement in the right eye. The initial case reports Vol. 5 No. 2: 139-46 142 visual acuity of the right eye was 20/400, and explained the symptomatology, but they were 20/20 in the left. negative (Table 2). One month after the onset of symptoms, Table 1. Vitreous humor tests using the PCR technique. during the second ophthalmology evaluation, the visual acuity of the right eye was 20/200 Test Patient Reference outcome value and of the left eye, 20/30, with biomicroscopy Real-time PCR Not detected <10 copies of the right eye that showed grade 2 vitreous for herpesvirus hemorrhages and subhyaloid hemorrhage with Real-time PCR Positive from <10 copies temporary exsanguinated vessels in the inferior for EBV cycle 31.4 nasal quadrant in the periphery, pale colored Real-time PCR Not detected <10 toxoplasmas macula with exsanguinated vessel in the inferior for Toxoplasma temporal arch, and difficult detail of the papilla. gondii The subhyaloid hemorrhage also presented Real-time PCR Not detected <10 copies with temporary intraretinal hemorrhages, so a for CMV possible infectious etiology was considered; PCR: polymerase chain reaction; EBV: Epstein-Barr virus; management was initiated with Aciclovir at the CMV: cytomegalovirus. doses described above. Source: Own elaboration. In October 2017, an ocular ultrasound showed severe low and medium reflectivity Table 2. Blood tests. vitreous opacities with denser membrane for- Test Patient outcome Reference mation in the lower quadrants, posterior vitreous value detachment with inferior traction and severe IgG CMV >500 U/mL >1 subhyaloid opacities; the head of the optic nerve IgM CMV Negative 0.04 >0.9 had normal appearance, so a picture compatible IgG Herpes Positive 39.9 >11 with severe vitritis, mixed opacities suggestive IgM Herpes Negative 0.74 <9 of bleeding areas, and inferior traction of the Elisa HIV Negative 0.18 <0.9 retina was considered. CD4 lymphocyte 611 cell /mm3 Because of the reported changes, the pa- count tient was taken to subsequent vitrectomy with Serology syphilis endolaser plus air for diagnostic purposes in screening order to take samples for PCR (polymerase chain Chemilumines- 0.09 non-reactive <0.9 reaction), cytomegalovirus (CMV), herpesvirus
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