Ophthalmic manifestations of subacute sclerosing panencephalitis

Ocular findings in subacute sclerosing panencephalitis

PURPOSE

The aim of this study was to evaluate the ocular manifestations of subacute sclerosing panencephalitis (SSPE) and to investigate possible risk factors in a relatively large series of patients.

METHODS

In this prospective study, patients who were diagnosed with SSPE and had undergone ophthalmic examination were included.

RESULTS

Of the 59 patients with SSPE, 25 (42.4%) had ocular findings. Ocular involvement was bilateral in 22 (88%) patients. The most characteristic fundus findings in our patients were chorioretinitis. No significant difference was found between the two groups in terms of age, gender, clinical stage, and ocular findings.

CONCLUSIONS

Although ophthalmological findings do not constitute a part of the diagnostic criteria, and the correlation between the clinical stage of SSPE and the ocular findings is unclear, patients with SSPE should be screened and followed up for ocular involvement.

Pseudotumor cerebri secondary to subacute sclerosing panencephalitis

Unusual presentations are not rare in subacute sclerosing panencephalitis. Five patients initially diagnosed with pseudotumor cerebri were ultimately determined to have pseudotumor cerebri secondary to subacute sclerosing panencephalitis. The present study retrospectively reviewed 56 cases history, neurologic symptoms, and clinical and laboratory data, as well as the outcomes. On admission, five patients (group 1) presenting with pseudotumor cerebri exhibited bilateral papilledema, and in each of them cranial magnetic resonance imaging revealed small lateral ventricles, effacement of the subarachnoid space, and no mass lesion. On admission, 51 patients (group 2) had no pseudotumor cerebri findings. The year of original measles infection, the interval between measles and onset of subacute sclerosing panencephalitis, and initial neurologic symptoms were similar, but length of symptoms before diagnosis of subacute sclerosing panencephalitis was shorter in group 1, and the clinical stage of subacute sclerosing panencephalitis on admission was more advanced in group 2. Cerebrospinal fluid mean open pressure was 378 +/- 22 H(2)O in group 1 and 146 +/- 28 H(2)O in group 2; cerebrospinal fluid antibody was 2038 +/- 768 U/L in group 1 and was 664 +/- 214 U/L in group 2. Only three of the five patients with pseudotumor cerebri had typical periodic discharges on electroencephalographic examination. These findings suggest that subacute sclerosing panencephalitis can cause pseudotumor cerebri.

Increasing exotropia and decreasing vision in a school-aged boy

An 8-year-old boy presented with bilateral visual loss and an increasing exotropia, and later developed deteriorating school performance. Magnetic resonance imaging of the head showed bilateral, symmetric, T2, and FLAIR white matter abnormalities in the parieto-occipital regions. Elevated serum very long chain fatty acids confirmed the diagnosis of X-linked adrenoleukodystrophy. Ophthalmologists should be aware of the diagnosis in boys with visual loss, hyperactivity, behavioral changes, and deterioration in school performance. Visual loss may be the presenting or predominant feature in X-linked adrenoleukodystrophy.

Pseudotumor cerebri secondary to subacute sclerosing panencephalitis

Pseudotumor cerebri is characterized by signs of raised intracranial pressure occurring in the absence of obvious brain pathology. We present an 8-year-old boy with pseudotumor cerebri secondary to subacute sclerosing panencephalitis. The reported patient suggests a possible association between subacute sclerosing panencephalitis and pseudotumor cerebri and that subacute sclerosing panencephalitis should be added to the list of disorders known to be associated with pseudotumor cerebri. Patients with subacute sclerosing panencephalitis might benefit from treatment aimed at increased intracranial pressure.

Measles blindness

Measles remains a major problem in developing countries, where it affects an estimated 30 million children a year and causes up to one million deaths annually. Measles blindness is the single leading cause of blindness among children in low income countries, accounting for an estimated 15,000 to 60,000 cases of blindness per year. There is a close synergism between measles and vitamin A deficiency that can result in xerophthalmia, with corneal ulceration, keratomalacia, and subsequent corneal scarring or phthisis bulbi. High-dose oral vitamin A supplementation is recommended for all children with measles in developing countries. Higher measles immunization coverage to interrupt measles transmission and interventions aimed at improving vitamin A nutriture of children are the main strategies to prevent measles blindness.

Uveitis with neurological manifestations

Neurological symptoms are not rare in patients with various uveitic syndromes, and they can be used as a guide to diagnosis. Some of the findings are nonspecific, but others can be typical of certain pathological conditions (table). After combining the information obtained in the medical history with the physical examination, target-oriented laboratory and diagnostic tests may then be obtained to confirm a diagnosis. Neurological manifestations can be of great value throughout this process and clearly should be carefully evaluated in every patient with uveitis.

Virus infections of the eye

In reviewing the clinical features, diagnostic evaluations and therapies of the most common ocular viral infections we attempt to whet your appetite for attacking the numerous challenges in diagnosis and treatment of viral eye disease. The herpes viruses, HSV, VZV and CMV are the cause of significant ocular morbidity. HSV most commonly affects the cornea producing keratitis that can be recurrent and may lead to corneal clouding and neovascularisation. Manifestations can be purely infectious or immunological and treatment options must be tailored to the underlying pathophysiology. Herpes zoster ophthalmicus, caused by VZV infection of the first branch of the trigeminal nerve, produces a characteristic rash and can progress to keratitis and uveitis. HSV and VZV can cause retinitis in both immunocompetent and immunocompromised individuals. There has been a significant increase in the incidence of CMV retinitis since the beginning of the AIDS epidemic. We review the numerous new treatments, diagnostic tests and treatment strategies which have been developed in response to this potentially blinding retinal infection. Adenovirus produces an epidemic conjunctivitis and epidemic keratoconjunctivitis which are severe and extremely contagious conjunctival infections. HIV, molluscum contagiosum, EBV and rubeola also cause ocular diseases which are described.Copyright 1998 John Wiley & Sons, Ltd.

Subacute sclerosing panencephalitis manifesting as viral retinitis: clinical and histopathologic findings

PURPOSE AND METHODS

To describe the clinical and histopathologic features of a patient with viral retinitis secondary to subacute sclerosing panencephalitis.

RESULTS

The patient was a human immunodeficiency virus-negative intravenous drug abuser with an acute retinitis that later progressed to encephalitis despite aggressive treatment for possible viral, protozoal, bacterial, and rickettsial infections. The patient had many of the characteristic findings of subacute sclerosing panencephalitis, including a history of measles in early childhood, myoclonus, periodic complexes on electroencephalographic testing, persistently elevated serum and cerebrospinal fluid antimeasles immunoglobulin G (IgG) titers, and a cerebrospinal fluid oligoclonal IgG gammopathy. Ultrastructural examination demonstrated numerous filamentous microtubular intranuclear viral inclusions in the nuclear layers of the retina consistent with the measles virus. This case is unusual in that our patient developed subacute sclerosing panencephalitis later in life and because there was an 8-year period between presumed viral infections in the two eyes.

CONCLUSIONS

An acute retinitis in an intravenous drug abuser is not always caused by human immunodeficiency virus-related infections; not all viral retinitis responds to therapy; and mortality as well as the usual morbidity may be associated with viral retinitis. One might consider the diagnosis of subacute sclerosing panencephalitis in a young person with an acute retinitis with little or no vitreal inflammation and lack of response to anticytomegalovirus and antitoxoplasmosis therapy.

Subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE), a neurodegenerative disease caused by a persistent "slow virus infection" with a mutated measles virus, is endemic in much of the developing world. Its incidence will increase in the USA, not only in immigrants, but also because of the 1988-1990 measles epidemic. This report reviews the pathogenesis, clinical and laboratory diagnosis, and future perspectives in treatment and prevention.

Eye pathology associated with measles encephalitis in hamsters

Measles encephalitis was produced in 41 hamsters by intracerebral injection of the hamster-neuroadapted Mantooth HBS viral strain. Group I (n = 10) included 2-day old (newborn) hamsters, each inoculated with 0.02 ml of 1:20 diluted virus. This group was sacrificed 4 days postinoculation (DPI). Group II (n = 31) included 25-day old hamsters, each inoculated with 0.03 ml of 1:10 diluted virus. This group was sacrificed 6, 13, 17, and 31 DPI. Clinical and histological evidence of measles encephalitis was present in all infected hamsters. Retinal lesions varied with the age of the animals at the time of inoculation. Retinal folds were observed in the 2-day old group and represented one form of retinal dysplasia. In the 25-day old group, however, earliest retinal involvement was in the form of hemorrhages, followed by focal retinitis in animals sacrificed 6-17 DPI. Measles keratitis was noted only in animals sacrificed 6 DPI. In 25-day old hamsters, measles keratitis and retinal hemorrhages represented the acute manifestations, whereas retinitis occurred later. However, ocular involvement did not correlate with the degree of severity of measles encephalitis.

Chorioretinitis as a possible very early manifestation of subacute sclerosing panencephalitis

Ocular changes occur in up to 50% of cases of subacute sclerosing panencephalitis (SSPE) usually at the same time as other neurological signs. Occasionally, visual symptoms precede other manifestations by a few weeks or months. Fundal changes (most commonly a macular chorioretinitis) are the most frequent ocular manifestation of SSPE. Inclusion bodies occur in the retina of patients with chorioretinitis and SSPE and it is believed that the lesions are due to actual viral invasion. We report a case of SSPE in which an atypical chorioretinitis preceded the onset of the typical clinical features of the disease by almost two years. Our case is unusual because of the long interval between the visual symptoms and the onset of other features of SSPE. We wish to emphasise the importance of thinking of SSPE in cases of chorioretinitis which are atypical or occur in young patients. Although treatment of SSPE thus far has been mostly disappointing, earlier diagnosis may offer the hope of better results.

Visual loss with dancing extremities and mental disturbances

A case is reported of a teenage girl, who presented with a profound loss of vision in the right eye, secondary to retinal vasculitis. During the preceding year, a gradual change in her personality had been noted, associated with a deterioration in her intellect. She developed an area of pigment epithelial disturbance in the macular region of the right eye, and subsequently, optic atrophy. One year after this, she had a similar, but more localized episode in the left eye. She later developed involuntary movements, and two years after initial presentation, a diagnosis of subacute sclerosing panencephalitis was made. Subsequently her clinical condition deteriorated rapidly and she died. Post-mortem examination confirmed the diagnosis of subacute sclerosing panencephalitis. This case demonstrates the insidious nature of the disease and suggests that the diagnosis of subacute sclerosing panencephalitis should be considered in any child or young adult who presents with unexplained retinal vasculitis, maculopathy or chorioretinitis.

Subacute sclerosing panencephalitis: fundus changes and histopathologic correlations

This paper describes the fundus changes in 2 patients with subacute sclerosing panencephalitis (SSPE). In both cases the ocular involvement preceded the neurological symptoms by several months. In one patient a localized serous detachment in the macular region was associated with retinal infiltrates and in the second patient an atypical unilateral macular chorioretinitis was first diagnosed. The diagnosis of SSPE was suspected when neurological signs appeared and it was confirmed by the typical EEG changes and especially by the high titers of measles antibodies in serum and CSF. The affected left eye of the second patient could be studied histopathologically and presented mainly pigment epithelial changes at the level of the scar, edema of the external plexiform layer, retinal folds and a detachment and rupture of the internal limiting membrane.

Subacute sclerosing panencephalitis (SSPE). A case report

A report is given of the fundus changes in a 17-year-old boy suffering from SSPE, which clinically first manifested itself by visual disturbances. At first the right eye showed extensive yellowish-white oedema at the posterior pole, surrounded by smaller round, yellow, partly confluent lesions, passing into a scarring stage in about ten days. Fluorescein angiography of the right eye was performed, both in the acute stage, which suggested a Harada syndrome, and in the scarring stage, which resembled a disseminated chorioretinitis. Three weeks later, during the development of the general neurological symptoms, the left eye developed the same fundus picture and course as the right eye. The condition of the patient rapidly deteriorated, leading to death five weeks after the onset of his visual complaints.

Visual deterioration as presentation of subacute sclerosing panencephalitis

A 7-year-old boy presented with deteriorating vision and macular degenerative changes. A month later he had developed unusual behaviour and increasing forgetfulness. An electroencephalogram showing periodic complexes, and high measles complement-fixation titres in the cerebrospinal fluid and blood, confirmed the diagnosis of subacute sclerosing panencephalitis. Four months after the onset of visual symptoms he started having myoclonic jerks.

Subacute sclerosing panencephalitis

A 17-year-old white woman had an acute left maculopathy of unknown etiology. She was in excellent health and had only had rubeola at 3 years of age. Hruby lens examination of the left eye, visual acuity of 6/60 (20/200), revealed a normal vitreous, macular edema, intraretinal hemorrhage, and cotton-wool exudates. Xenon photo-coagulation was performed on the left eye. The visual acuity remained 6/60 (20/200) with drying of the retina. The patient remained in excellent health until 22 months after the initial ocular problem when she developed a left homonymous hemianopia. Then her mind deteriorated, and she became demented. We diagnosed subacute sclerosing panencephalitis after finding an increased spinal fluid gamma globulin, raised serum and spinal fluid titers of measles antibodies, and an electroencephalogram pathognomonic for this condition.

Immunosuppression and eye disease. First Vail lecture

Several viral, fungal, and protozoal diseases of the eye are significantly associated with immunologic deficiencies. Of the viral agents, cytomegaly and herpes simplex and zoster cause a discrete necrotizing retinopathy that has the characteristics of vascular occlusion. Measles may result in a delayed retinopathy that is predominantly macular and associated with subacute progressive encephalopathy. Of the fungal agents, Candida and Aspergillus are apt to involve the eye, beginning as choroidal lesions with extension forward to involve the pigment epithelium and retina secondarily. Mucor and Cryptococcus are less common. Toxoplasmosis is the one ocular protozoal disease whose incidence is increased by immunosuppression, and, like the viral diseases, is characterized by a discrete necrotizing retinopathy and probably results from activation of dormant organisms in the retina. Autoimmunity undoubtedly plays an important role in eye disease but its ocular pathogenesis is obscure.

Slow virus infections

Slow viruses produce diseases whose incubation periods range from several months to many years. Because of this long latency period, the lack of inflammation produced by these diseases and the lack of recoverable virus particles, it is only recently that the association has been made between the viruses and the diseases they cause. The detailed study of kuru, a neurologic affliction of a remote tribe of cannibals in New Guinea, was responsible for the synthesis of new and previously gathered information into a unified framework to explain not only kuru but other diseases as well. Since then, animal models, transmission experiments and histologic and biochemical studies have unveiled new links connecting viruses to previously obscure neurologic, neurophthalmic and ophthalmic entities.

Ophthalmoscopic findings in subacute sclerosing panencephalitis

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