Incidental multiple myeloma in a patient with neuroretinitis: a case report

BACKGROUND

Neuroretinitis is classically defined as a clinical triad of unilateral, painless vision loss, accompanied by optic disc edema and characteristic macular star formation. The causes of neuroretinitis can be categorized as infectious, non-infectious, and idiopathic, therefore differential diagnosis and careful evaluation are required, owing to the various etiologies and masqueraders.

CASE PRESENTATION

A 54-year-old woman presented to the clinic with blurred vision in both eyes. A complete ophthalmic examination revealed optic disc edema with blurred margins and macular exudates, intraretinal edema in the temporal peripapillary area, and subretinal fluid with neurosensory retinal detachment in the macular area. Systemic laboratory investigations showed no signs of infection or inflammation. However, bone marrow suppression was suspected based on the results of the complete blood count test, and the patient was diagnosed with multiple myeloma.

CONCLUSION

Although neuroretinitis is rarely accompanied by hematological malignancy, it is important to be mindful of the latter because ophthalmic manifestations are a common feature of hematological malignancies and lesions occur in nearly every ocular structure.

A case report of isolated primary herpes-simplex virus neuroretinitis in an immunocompetent adult

Background

Herpes simplex virus (specifically HSV-1 and HSV-2) are greatly prevalent viruses that can cause conjunctivitis, keratitis and other rarer ocular disorders such as acute retinal necrosis syndrome or neuroretinitis. We report a case of an isolated unilateral neuroretinitis with primary HSV infection in an immunocompetent adult without other related clinical features.

Case presentation

A 60-year-old immunocompetent woman presented with sudden painless central vision loss in her left eye (best corrected visual acuity was 20/200) showing optic disc edema, submacular fluid and a delayed development of a macular star. The macular optical coherence tomography (OCT) showed a serous retinal detachment. Arterial hypertension or exposure to ionizing radiation were ruled out and the microbiological blood test battery was only positive for immunoglobulin M (IgM) for HSV-1 which allowed etiological treatment with oral valacyclovir. Complete resolution and good visual results were found within 3 months.

Conclusions

The present case of isolated neuroretinitis as a primary HSV infection in an immunocompetent patient was resolved with good functional results after valacyclovir treatment. Presence of HSV IgM in absence of other laboratory results could be enough evidence to start HSV treatment in immunocompetent patients with a macular star, as an isolated lesion, after ruling out other non-infectious causes, such as arterial hypertension or exposure to ionizing radiation. Rare infectious agents in immunocompetent patients must be considered in the differential diagnosis of neuroretinitis, even if there are no other typical symptoms or signs that could suggest the disease.

Rickettsial neuroretinitis: A report of 2 cases

Purpose

The authors present two cases of neuroretinitis caused by Rickettsia rickettsii infection.

Observations

Case 1 is a 24-year-old male who presented with 2 months of vision loss. Case 2 is a 38-year-old female who presented with 4 weeks of eye pain and vision loss. Examination of both patients revealed neuroretinitis characterized by optic disc swelling with macular exudates, and subsequent serological analysis was positive for Rickettsia rickettsii. Both patients responded favorably to treatment with oral doxycycline and prednisone.

Conclusions and importance

Given the potential for neuroretinitis to cause permanent vision loss, the presence of acute vision loss, optic disc edema, and macular exudates should prompt an evaluation for Rickettsial disease in endemic areas, even in the absence of systemic symptoms or known history of a tick bite.

Treatment Strategies for Neuroretinitis: Current Options and Emerging Therapies

PURPOSE OF REVIEW

To explore and critically appraise the published data on the current and emerging treatment modalities for neuroretinitis.

RECENT FINDINGS

The optimum treatment strategy for neuroretinitis due to Bartonella henselae in immunocompetent individuals is not clear and a matter of debate. The role of systemic corticosteroids in infectious neuroretinitis and the optimum immunosuppressive regimen for use in recurrent idiopathic neuroretinitis also remains ill defined. There is no class 1 evidence to support a specific treatment strategy for neuroretinitis. For uncomplicated B. henselae-associated neuroretinitis in immunocompetent patients, initiation of antibiotic and corticosteroid therapy remains controversial. In patients with severe vision loss and/or moderate to severe systemic symptoms, a 4- to 6-week regimen of doxycycline or azithromycin with rifampin may provide some benefit. The routine use of systemic corticosteroids in infectious neuroretinitis is not recommended. Targeted antimicrobial agents should be instituted in cases of neuroretinitis due to specific infectious etiologies (e.g., syphilis, Lyme disease, tuberculosis). Azathioprine may be beneficial in cases of recurrent idiopathic neuroretinitis. There is a need for collaborative, multicenter prospective studies to provide definitive guidelines regarding the use of antibiotics and corticosteroids and to evaluate future therapies in infectious and recurrent idiopathic neuroretinitis.

Leber's idiopathic stellate neuroretinitis: diagnostic and therapeutic conflicts

Three cases of patients with decreased visual acuity and papillitis at onset with subsequent macular star development after a few weeks are presented. Complementary tests were unremarkable in all included patients. Based on this clinical context, they were diagnosed with Leber's idiopathic stellate neuroretinitis, were treated with corticosteroids, as well as with antibiotics in 2cases. All patients showed favourable outcomes, although signs of papillary atrophy were observed in the affected eyes. Leber's idiopathic stellate neuroretinitis diagnosis can be challenging due to the wide spectrum of conditions that have to be ruled out. In addition, macular star may appear later on, which should not exclude its diagnosis. Use of antibiotics and/or corticosteroids is controversial considering its benign nature, but should be considered in selected severe cases. Moreover, the routine use of complementary tests should be carefully evaluated, mainly those that can be aggressive and/or expensive, which should be rationally used.

Refractory coats' disease of adult onset

Purpose

We present the case of an 18-year-old Caucasian male with a unilateral macular star and retinal vascular anomalies compatible with adult onset Coats’ disease.

Methods

Diagnosis was based on fundoscopic, fluorescein angiography and optical coherence tomography findings.

Results

The patient presented to our emergency department with complaints of low vision in his left eye (LE) detected 10 days before. The best-corrected visual acuity in the LE was 20/50. Fundoscopy of the LE evidenced a complete macular star. Optical coherence tomography showed increased retinal thickness, infiltration of the retinal wall, and detachment of the neuroepithelium. Angiography revealed no appreciable diffusion in the macula. Above the superior temporal (ST) arcade, anomalies in the retinal vasculature were found, with interruption of the peripheral vessels and vessels which were ‘sausage’-like. After 1 month, the LE vision evolved to hand movements. Laser photocoagulation was performed in the ST quadrant. Intravitreal injection of bevacizumab 1.25 mg/0.05 ml and photodynamic therapy were performed without any significant changes, progression of ST serous detachment of the neuroepithelium, and finally progression to macular fibrosis.

Discussion

Coats’ disease is usually diagnosed in childhood, but rare cases may occur in adults. Those cases usually have a more indolent course which was not observed in our patient. When there is macular involvement, prognosis is more guarded, despite treatment.