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Sassalos TM, Vitale AT, Conrady CD. Posterior scleritis and acute posterior multifocal placoid pigment epitheliopathy: A case of painful chorioretinitis and review of the current literature. Am J Ophthalmol Case Rep 2021; 23:101159. [PMID: 34278050 PMCID: PMC8261531 DOI: 10.1016/j.ajoc.2021.101159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/20/2021] [Accepted: 06/29/2021] [Indexed: 12/17/2022] Open
Abstract
Purpose To describe a patient who developed concurrent acute posterior multifocal placoid pigment epitheliopathy (APMPPE) and posterior scleritis. Observations We describe a middle-aged woman that developed eye pain and photopsia. She was found to have a “T-sign” on ultrasound of the right eye and multiple, nearly confluent, ill-defined subretinal whitish lesions in both eyes. After an extensive laboratory evaluation and neuroimaging, her photopsia, pain with eye movements, and subretinal lesions began to regress on high dose systemic corticosteroids. Conclusions and Importance This is the first reported case of bilateral APMPPE and concurrent posterior scleritis. Our case highlights the importance of performing a full review of systems, specifically eliciting neurological changes, and dilated eye examination in all new uveitis cases.
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Affiliation(s)
- Thérèse M Sassalos
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA
| | - Albert T Vitale
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Christopher D Conrady
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA
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Brownlee WJ, Anderson NE, Sims J, Pereira JA. Neurological complications of acute multifocal placoid pigment epitheliopathy. J Clin Neurosci 2016; 31:76-80. [PMID: 27183958 DOI: 10.1016/j.jocn.2016.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/13/2016] [Indexed: 10/21/2022]
Abstract
Acute multifocal placoid pigment epitheliopathy (AMPPE) is an autoimmune chorioretinal disease that can be complicated by neurological involvement. There is limited information on this potentially treatable condition in the neurological literature. The objective of this patient series is to describe the neurological complications of AMPPE. We retrospectively identified patients with neurological complications of AMPPE seen at Auckland Hospital between 2008 and 2013 and summarised cases in the literature between 1976 and 2013. We identified five patients with neurological complications of AMPPE at Auckland Hospital and 47 reported patients. These patients demonstrated a spectrum of neurological involvement including isolated headache, stroke or transient ischaemic attack, seizures, venous sinus thrombosis, optic neuritis, sensorineural hearing loss and peripheral vestibular disorder. We propose criteria to define AMPPE with neurological complications. A cerebrospinal fluid (CSF) lymphocytosis in a patient with isolated headache may predict the development of cerebrovascular complications of AMPPE. Patients with cerebrovascular complications of AMPPE have a poor prognosis with high rates of death and neurological disability among survivors. Predictors of poor outcome in those who develop neurological complications of AMPPE are a relapsing course, generalised seizures and multifocal infarction on MRI. All patients with neurological complications of AMPPE, including headache alone, should be investigated with an MRI brain and CSF examination. Patients with focal neurological symptoms should receive intravenous (IV) methylprednisolone followed by a tapering course of oral steroids for at least 3months. Patients with AMPPE and an isolated headache with a CSF pleocytosis should be treated with oral steroids.
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Affiliation(s)
- W J Brownlee
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - N E Anderson
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - J Sims
- Department of Ophthalmology, Auckland City Hospital, Auckland, New Zealand
| | - J A Pereira
- Centre for Brain Research, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
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Case D, Seinfeld J, Kumpe D, Folzenlogen Z, Jones W, Simpson J, Hughes R. Acute Posterior Multifocal Placoid Pigment Epitheliopathy Associated with Stroke: A Case Report and Review of the Literature. J Stroke Cerebrovasc Dis 2015; 24:e295-302. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 04/27/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022] Open
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Thomas BC, Jacobi C, Korporal M, Becker MD, Wildemann B, Mackensen F. Ocular outcome and frequency of neurological manifestations in patients with acute posterior multifocal placoid pigment epitheliopathy (APMPPE). J Ophthalmic Inflamm Infect 2012; 2:125-31. [PMID: 22573398 PMCID: PMC3438297 DOI: 10.1007/s12348-012-0077-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 04/22/2012] [Indexed: 10/31/2022] Open
Abstract
PURPOSE The purpose of this study was to describe the visual prognosis as well as the frequency and clinical severity of central nervous system involvement in all acute posterior multifocal placoid pigment epitheliopathy (APMPPE) patients of one centre. METHODS A retrospective database review of all patients and a prospective clinical, ophthalmological and neurological follow-up, if possible, were conducted. RESULTS Eighteen patients with APMPPE were included with a mean follow-up of 17.1 months. Thirteen patients participated in a follow-up exam. Visual acuity improved in 9 of 18 patients to a mean of 0.17 log minimum angle of resolution (MAR) in the worse eye and remained stable in eight patients (mean, 0.03 logMAR). In the majority of patients, the 30° static perimetry improved at follow-up compared to the initial exams. Still, in up to 50 to 60 %, small visual field defects persisted. Overall, 11 patients (61 %) showed neurologic symptoms of varying severity. The most common neurological symptom was headache in nine (50 %) patients. Other symptoms included paraesthesias, psychosis, vertigo, and, as the most severe complication, stroke due to cerebral vasculitis. Fifteen patients were treated with systemic corticosteroids. CONCLUSIONS Visual prognosis is good in patients with APMPPE, but visual field defects may remain. Neurological signs and symptoms, especially headaches, are frequent in APMPPE and should be taken seriously. Adequate investigations including MRI and CSF examination should be initiated in these patients.
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Affiliation(s)
- Bettina C Thomas
- Interdisciplinary Uveitis Centre, Department of Ophthalmology, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany,
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Joswig H, Flueckiger C, Infanger A, Tettenborn B, Felbecker A. Recurring meningoencephalitis in sinusitis-associated acute posterior multifocal placoid pigment epitheliopathy under prednisone tapering. BMJ Case Rep 2011; 2011:bcr.02.2011.3820. [PMID: 22696710 DOI: 10.1136/bcr.02.2011.3820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The authors describe a case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with recurrent neurological complications. A 24-year-old man experienced subacute bilateral visual loss. Based on the characteristic findings in funduscopy and fluorescin angiography and after the exclusion of the differential diagnoses, APMPPE was diagnosed. During the course of the disease recurrent episodes of meningitis and encephalitis occurred when tapering of prednisone was attempted. Secondary to encephalitic lesions, the patient developed partial epileptic seizures, which made an anticonvulsive medication necessary. The authors considered a chronic sinusitis to be an aetiological factor of the underlying autoimmune process. Due to the complicated course of APMPPE, they decided to start long-term immunosuppressive therapy with azathioprine under which the patient remained stable and prednisone could be tapered successfully. Neurological complications of APMPPE are rare. Nevertheless, this case demonstrates that long-term immunosuppressive treatment might be necessary to prevent recurrent neurological complications in some cases.
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Affiliation(s)
- H Joswig
- Department of Neurology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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Manto M, Cordonnier M, Blecic S, Legros B, Hildebrand J. Acute posterior multifocal placoid pigment epitheliopathy presenting as an aseptic meningitis. Eur J Neurol 2011; 2:181-3. [DOI: 10.1111/j.1468-1331.1995.tb00114.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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[Juvenile pontine infarction. Complication of acute posterior multifocal placoid pigment epitheliopathy]. DER NERVENARZT 2011; 82:496, 498-9. [PMID: 21221525 DOI: 10.1007/s00115-010-3118-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Liu GT, Volpe NJ, Galetta SL. Vision loss. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Kline DC, Vitale A, Warner JE. Acute Multifocal Placoid Pigment Epitheliopathy Associated with Cavernous Sinus Thrombosis. Ocul Immunol Inflamm 2009; 15:443-6. [DOI: 10.1080/09273940701732271] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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A Case of Acute Posterior Multifocal Placoid Pigment Epitheliopathy With Recurrent Stroke. J Neuroophthalmol 2009; 29:111-8. [DOI: 10.1097/wno.0b013e318199bfd9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jaramillo A, Gaete G, Romero P, Orellana P, Illanes S. Acute Pontine Infarct in a 16-Year-Old Man with Acute Posterior Multifocal Placoid Pigment Epitheliopathy. A Case Report. J Stroke Cerebrovasc Dis 2009; 18:164-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2008.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 08/18/2008] [Accepted: 08/26/2008] [Indexed: 10/21/2022] Open
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Blecic S. Rare causes of stroke. HANDBOOK OF CLINICAL NEUROLOGY 2009; 93:955-968. [PMID: 18804688 DOI: 10.1016/s0072-9752(08)93047-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Serge Blecic
- Hôpital Erasme, Service de Neurologie, Brussels, Belgium.
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Affiliation(s)
- Robin Ray
- Neuro-ophthalmology Service, Baylor College of Medicine, 6565 Fannin NC-205, Houston, TX 77030, USA
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Illoh K, Sitton C, Fish R, Grotta J. Acute Posterior Multifocal Placoid Pigment Epitheliopathy After Cerebral Sinus Thrombosis. Neuroophthalmology 2007. [DOI: 10.1080/01658100701501034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Behbehani R, Al-Mutairi S. Headache and vision loss in a 41-year-old man. Lancet Neurol 2006; 5:458-62. [PMID: 16632317 DOI: 10.1016/s1474-4422(06)70445-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Raed Behbehani
- Al-Bahar Ophthalmology Centre, Safat, Kuwait City, Kuwait
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Acute Multifocal Placoid Pigment Epitheliopathy. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50110-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Hsu CT, Harlan JB, Goldberg MF, Dunn JP. Acute posterior multifocal placoid pigment epitheliopathy associated with a systemic necrotizing vasculitis. Retina 2003; 23:64-8. [PMID: 12652233 DOI: 10.1097/00006982-200302000-00010] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The authors present a case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) associated with a systemic necrotizing vasculitis with mixed features of Wegener granulomatosis and polyarteritis nodosa (PAN). METHODS Case report. RESULTS A 29-year-old woman developed a severe nosebleed, followed by a low-grade fever, night sweats, and a productive cough. One month later, she began experiencing high fevers, headache, myalgia, neck stiffness, and abdominal pain as well as bilateral blurred vision from APMPPE. Systemic evaluation revealed nasal ulcerations, bilateral pleural effusions, and a bilateral maxillary and ethmoid sinusitis, consistent with Wegener granulomatosis. However, ANCA testing was negative, and a renal and mesenteric angiogram showed aneurysmal dilatations suggestive of PAN. Her ocular and systemic symptoms markedly improved with systemic corticosteroids. CONCLUSIONS The cause of APMPPE is unknown. This case of APMPPE associated with systemic necrotizing vasculitis provides support for the choroid as being primarily involved by a diffuse vasculitic process that interrupts choroidal perfusion and causes the characteristic fundus findings in APMPPE.
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Affiliation(s)
- Cynthia T Hsu
- Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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O'Halloran HS, Berger JR, Lee WB, Robertson DM, Giovannini JA, Krohel GB, Meckler RJ, Selhorst JB, Lee AG, Nicolle DA, O'Day J. Acute multifocal placoid pigment epitheliopathy and central nervous system involvement: nine new cases and a review of the literature. Ophthalmology 2001; 108:861-8. [PMID: 11320014 DOI: 10.1016/s0161-6420(01)00565-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE The authors describe nine new cases of acute multifocal placoid pigment epitheliopathy (AMPPE) with associated central nervous system (CNS) involvement and permanent visual sequelae. The study includes a review of the literature and discussion of evaluation, management, and treatment options. DESIGN Retrospective, noncomparative case series. PARTICIPANTS Nine patients were identified with AMPPE and CNS involvement in addition to 22 patients reviewed in the literature. MAIN OUTCOME MEASURES A review of nine patients with AMPPE and CNS involvement was performed. Charts were reviewed for age, gender, preceding viral prodromes, visual acuity, ophthalmologic examination findings, CNS findings, and treatment. RESULTS Thirty-one patients (nine new patients) were diagnosed with AMPPE and various degrees of CNS involvement. Ages ranged from 8 to 54 years, with an average of 27 years. Twenty-one males (68%) and 10 females (32%) were identified. Eleven patients (35%) had antecedent viral illnesses. Visual acuity was variable and ranged from 20/20 to count fingers. The spectrum of CNS findings ranged from headaches to sagittal sinus thrombosis. CONCLUSIONS Acute multifocal placoid pigment epitheliopathy can be associated with CNS abnormalities and permanent visual deficits. Neuroimaging, lumbar puncture, and cerebral angiography analysis provide useful diagnostic tools when CNS involvement is suspected. Intravenous corticosteroids and collaboration with neurovascular colleagues should be considered in these situations. In cases complicated by CNS arteritis, immunosuppressive agents can be a beneficial adjunct to corticosteroids.
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Affiliation(s)
- H S O'Halloran
- Department of Ophthalmology, University of Kentucky, Lexington, KY 40536, USA.
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Comu S, Verstraeten T, Rinkoff JS, Busis NA. Neurological manifestations of acute posterior multifocal placoid pigment epitheliopathy. Stroke 1996; 27:996-1001. [PMID: 8623125 DOI: 10.1161/01.str.27.5.996] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a chorioretinal disease that causes acute visual symptoms with characteristic fundus findings. Although this entity has been associated with a variety of neurological complications, it has received little attention in the neurological literature. We wanted to emphasize the spectrum of neurological involvement, in particular the occurrence and management of strokes in patients with APMPPE. CASE DESCRIPTIONS We report three patients with APMPPE and neurological disease. All three presented with marked visual disturbances and headaches. One patient developed recurrent strokes involving different vascular territories of the brain and required immunosuppressive treatment for presumed cerebral vasculitis. The other two patients had cerebrospinal fluid pleocytosis and persistent headaches but recovered spontaneously. The review of the literature demonstrates a particular pattern of neurological complications in a subgroup of patients with APMPPE. CONCLUSIONS APMPPE should be considered among the causes of stroke and aseptic meningitis in young adults. The diagnosis is critically dependent on a thorough ophthalmologic examination. Severe neurological complications are difficult to predict at the onset of the ophthalmologic disease. The patients should be monitored closely. If investigations suggest cerebral vasculitis, immunosuppressive treatment may be helpful to prevent recurrences.
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Affiliation(s)
- S Comu
- Division of Child Neurology, University of Pittsburgh School of Medicine, Pa., USA
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