Dengue Fever Presenting as Purtscher-like Retinopathy

Purtscher's and Purtscher-like retinopathy etiology, features, management, and outcomes: A summative systematic review of 168 cases

BACKGROUND

To describe Purtscher's and Purtscher-like retinopathy clinical features, etiologies, management options, and visual outcomes.

METHODS

Our protocol was registered on PROSPERO [registration number: CRD42023406843]. Seven online databases were searched: PubMed, Scopus, Medline, ScienceDirect, CENTRAL, clinicaltrials.gov, and Google Scholar. Original articles were included if they reported at least one subject diagnosed with Purtscher's or Purtscher-like retinopathy. The primary outcome is to describe the clinical features of Purtscher and Purtscher-like retinopathies, including etiologies, results of related investigations, management lines, and visual outcomes. All analyses were conducted with the use of Statistical Package for Social Sciences (SPSS) version 27 (IBM SPSS Corp, SPSS Statistics ver. 26, USA) and Cochrane's RevMan software. The methodological quality of included studies was assessed using the NIH quality assessment tools.

RESULTS

A total of 114 articles were included, describing 168 cases of Purtscher's and Purtscher-like retinopathy. Patients were evenly distributed between males (50.89%) and females (49.11%). Average age of patients was 34.62 years old. Trauma was the leading cause of retinopathy, being reported in 39.88% of our patients, followed by systemic lupus erythematosus (SLE) (13.1%) and acute pancreatitis (11.9%). Bilateral symptoms were reported in 57.7% of patients with centrally blurred vision being the most complained symptom (OS: 34.32% and OD: 18%). 75% of patients elicited bilateral retinal findings. Cotton-wool spots were of highest prevalence (58%). Purtscher flecken was seen in 53% of patients. Macular edema was seen in 13% of patients. Overall, patients had a favorable prognosis (53%).

CONCLUSION

Purtscher's and Purtscher-like retinopathies are rare sight-threatening retinopathies that develop most commonly following trauma or other systemic diseases as SLE and acute pancreatitis. Little data is available regarding these conditions, and available data is of low quality. Patients develop bilateral disease in approximately 50% of cases, and several retinal findings are observed, with no specific tendency. Most observed signs are cotton-wool spots in around 55% of patients and Purtscher flecken in 51% of patients. Patients spontaneously recovered, although data is not conclusive. No clear prognostic value of etiological factors is identified, and further research is required in this regard.

Purtscher-like Retinopathy in a Patient with Systemic Sclerosis: A Case Report and Narrative Review

Purtscher-like retinopathy (PLR) is an uncommon occlusive microangiopathy associated with various systemic conditions. We report a case of PLR related to severe progressive systemic sclerosis (SSc), an autoimmune disease characterized by widespread angiopathy and fibrosis, in a 44-year-old Caucasian male diagnosed with early diffuse cutaneous systemic sclerosis (dSSc). Upon ophthalmological examination, pathognomonic fundoscopy abnormalities were found. Spectral domain optical coherence tomography (SD-OCT), angio-OCT, and visual field results are documented at initial diagnosis and follow-up visits. The detailed ophthalmological assessment is juxtaposed with rheumatological evaluation and treatment. Current literature on probable pathophysiological mechanisms is reviewed in accordance with the described case. The PLR seems to be connected to severe SSc-related angiopathy initiated by capillary endothelial damage, with ultimate arteriolar precapillary occlusion in the inner retinal layer. Although this is not routinely recommended, we suggest that ophthalmological examinations may be advantageous in patients with SSc, as serious eye pathology may be present despite the lack of symptoms reported by the patient. Patients with PLR require a differential diagnosis and regular follow-up. Proper treatment of the underlying disease may have beneficial effects on the natural course of PLR.

Acute macular neuroretinopathy associated to dengue disease

Purpose

To highlight an interesting case of Acute Macular Neuroretinopathy (AMN) in the context of dengue disease.

Observations

A 70 year old woman from Ibagué, Colombia developed AMN during her hospitalization for dengue illness with warning signs. Her initial ophthalmic evaluation revealed a deep visual loss with no noticeable biomicroscopic findings and altered outer retinal layers in her macular optical coherence tomography (OCT). After a five year follow up, she maintains a poor visual acuity.

Conclusions and Importance

There are few reported cases of AMN associated to dengue. This case report highlights the common physiopathological pathways between dengue and AMN, and the crossroads between vascular, infectious, and immune disorders.

Multitarget microangiopathy in a young healthy man with COVID-19 disease: A case report

A 41-year-old man presented to the emergency department complaining of decrease of vision in his left eye. Initial examination was consistent with retrobulbar optic neuritis, and an intravenous drip of methylprednisolone was started. On the third day, the fundus examination revealed the appearance of multiple Purtscher-like cotton-wool spots in the posterior pole and nasally to the optic disc, slight retinal whitening around the fovea, and cherry-red spot. The patient reported flu-like symptoms, and he tested positive at PCR (polymerase chain reaction) test for 2019-nCoV (2019 novel coronavirus) infection. Assuming possible 2019-nCoV-related vascular damage, we prescribed low-molecular-weight heparin. The lesions were regressing at follow-up, and we registered a complete visual recovery.

Acute neurologic emerging flaviviruses

The COVID-19 pandemic has shed light on the challenges we face as a global society in preventing and containing emerging and re-emerging pathogens. Multiple intersecting factors, including environmental changes, host immunological factors, and pathogen dynamics, are intimately connected to the emergence and re-emergence of communicable diseases. There is a large and expanding list of communicable diseases that can cause neurological damage, either through direct or indirect routes. Novel pathogens of neurotropic potential have been identified through advanced diagnostic techniques, including metagenomic next-generation sequencing, but there are also known pathogens which have expanded their geographic distribution to infect non-immune individuals. Factors including population growth, climate change, the increase in animal and human interface, and an increase in international travel and trade are contributing to the expansion of emerging and re-emerging pathogens. Challenges exist around antimicrobial misuse giving rise to antimicrobial-resistant infectious neurotropic organisms and increased susceptibility to infection related to the expanded use of immunomodulatory treatments. In this article, we will review key concepts around emerging and re-emerging pathogens and discuss factors associated with neurotropism and neuroinvasion. We highlight several neurotropic pathogens of interest, including West Nile virus (WNV), Zika Virus, Japanese Encephalitis Virus (JEV), and Tick-Borne Encephalitis Virus (TBEV). We emphasize neuroinfectious diseases which impact the central nervous system (CNS) and focus on flaviviruses, a group of vector-borne pathogens that have expanded globally in recent years and have proven capable of widespread outbreak.

COVID-19 Retinal Findings in Patients Admitted to Intensive Care Units and Wards

The main purpose of this study was to investigate ocular clinical findings in patients with confirmed COVID-19 infection, of various levels of disease severity, who required mechanical ventilation and admission to intensive care units or specialized wards. Longitudinal, observational study conducted from March 2020 to June 2020. Color fundus and red-free photography were performed in both eyes following pupillary dilation. 104 participants were recruited from 2 different centers: 60 (58%) from the Hospital Municipal de Barueri intensive care unit (ICU) and 44 (42%) from specialized wards for patients with COVID-19 at the Hospital São Paulo. 21.9% presented with eye lesions, in 3% these lesions were vision compromising. Our results have shown similar rate of intraocular lesions in patients in both the ward or intensive care unit, regardless of medication use, including anticoagulant drugs.

Purtscher-like Retinopathy Associated with Crimean-Congo Hemorrhagic Fever: A Case Report

PURPOSE

To describe retinal findings and spectral-domain optical coherence tomographic (SD-OCT) features of a patient with Crimean-Congo hemorrhagic fever (CCHF) presenting as Purtscher-like retinopathy.

CASE REPORT

A 70-year-old woman presented with the emerging bilateral blurring of vision. She had been diagnosed with CCHF one week ago and hospitalized in another hospital for treatment of disease. Fundoscopy of the patient revealed cotton-wool spots, retinal whitening areas, and few retinal hemorrhages in a Purtscher-like configuration in both eyes. Spectral-domain optical coherence tomography revealed inner retinal hyperreflectivity corresponding to the cotton-wool spots in both eyes, and also showed subretinal fluid in the left eye. Without any treatment retinal lesions and inner retinal hyperreflectivity on SD-OCT regressed within one month.

CONCLUSION

Crimean-Congo hemorrhagic fever is known to cause mild ocular disease, and may also cause Purtscher-like retinopathy. It is important to aware of the ocular findings of CCHF.