Subacute sclerosing panencephalitis

Ocular effects caused by viral infections and corresponding vaccines: An overview of varicella zoster virus, measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2

Many viral infections can affect vision and the visual system. Vaccination to prevent diseases is commonplace today, acting by stimulating an immune response without developing the pathology. It involves the production of persisting antibodies against the pathogen and the activation of T cells. Certain diseases have already been eradicated by rigorous vaccination campaigns, while others are hoped to be eliminated soon. Vaccines currently available on the market are largely safe, even if they can rarely cause some adverse effects, such as ocular complications. Analyzing existing literature, we aimed to compare the pathological effects on the eye due to the most common viral infections [in particular varicella zoster virus (VZV), measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2] with the possible ocular adverse effects of their relative vaccines, in order to establish a risk-benefit relationship from an ophthalmological point of view.

Subacute sclerosing panencephalitis: a cause of acute vision loss

A 4-year-old male presented with only acute vision loss. His neurologic examination, funduscopic examination, and pupils were normal. Cranial magnetic resonance imaging revealed abnormal hyperintense, bilaterally symmetric lesions (on T(2)-weighted and fluid-attenuated inversion recovery, images) in bilateral optic radiations, pulvinar region in the thalami, crus posterior of internal capsules, periventricular white matter, and unilaterally left anterior pons. Elevated measles antibody titers in the cerebrospinal fluid confirmed the diagnosis of subacute sclerosing panencephalitis. Vision loss improved and cranial magnetic resonance imaging findings regressed,but myoclonic jerks and deterioration began 7 months later. The diagnosis of subacute sclerosing panencephalitis should be considered in cases with acute vision loss resulting from cortical blindness even when classical findings of the central nervous system do not exist.

Subretinal lesions in subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE) is a rare progressive neurologic disorder. A 9-year-old boy was seen who had progressive neurocognitive decline, myoclonic jerking of the extremities, and an abnormal result of an electroencephalogram (EEG). Ophthalmoscopic examination revealed multifocal subretinal lesions. The diagnosis of SSPE was made on the basis of the clinical examination and elevated serum and spinal fluid measles titer. We describe subretinal lesions in a patient with SSPE.

Adult-onset subacute sclerosing panencephalitis: case reports and review of the literature

Subacute sclerosing panencephalitis (SSPE) is mainly thought of as a disorder of childhood and adolescence and may not be readily recognized when presenting later in life. Prior reports have suggested that adult-onset SSPE may have atypical features. We have added two cases to the existing literature on adult-onset SSPE, compared them with a more classic juvenile presentation, and extensively reviewed those reports that were published after the etiological link with the measles virus had been established. Adult-onset SSPE patients present at a mean age of 25.4 years (range 20-35 years). They have a higher proportion of either negative history of measles exposure or undocumented history by the reporting authors. Those with available history of measles exposure tend to have it either earlier (younger than 3 years old) or later (after 9 years) than the usual childhood measles infection. Where the primary infection is known, unusually long measles-to-SSPE intervals have been documented, ranging from 14 to 22 years. None of the cases followed measles vaccination. Visual symptomatology was very frequent, with 8 of the 13 cases reviewed having a purely ophthalmological presentation; only 2 patients presented with behavioral changes. Although the course of the disease was progressive and fatal in the majority, there appeared to be a higher rate of spontaneous remission as compared with childhood-onset SSPE. Myoclonus, spastic hemiparesis, bradykinesia, and rigidity were the predominant motor manifestations. Neuropathology revealed cortical and subcortical gray matter involvement preferentially of the occipital lobes, thalamus, and putamen. The importance of recognizing the spectrum of potential presentations of SSPE and providing an early diagnosis will increase as more effective treatments become available.

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.

Systemic viral infections and their retinal and choroidal manifestations

Viruses are one of the most common causes of infections involving the posterior segment of the eye. Such infections can occur either on a congenital or an acquired basis, and may affect primarily the retina or the choroid. Congenital cytomegalovirus (CMV) and rubella infections may result in retinitis. CMV retinitis is also the most common cause of acquired viral retinitis, primarily because of the acquired immunodeficiency syndrome (AIDS). Other types of viral retinitis, such as those caused by herpes simplex or herpes zoster, can occur in immunocompromised or immunocompetent individuals. Retinitis or choroiditis caused by viruses such as measles, influenza, Epstein-Barr virus, and Rift Valley fever virus, typically occurs subsequent to an acute viral systemic illness. The systemic and ocular manifestations, as well as the histopathology, laboratory tests, differential diagnoses, and treatment regimens for each of the individual viruses are discussed in detail.

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.

Acute multifocal hemorrhagic retinal vasculitis

The authors present a series of seven patients with acute visual loss associated with mild anterior uveitis, multifocal retinal vasculitis, retinal capillary nonperfusion, retinal hemorrhage, disc swelling, and vitreitis. Oral prednisone was of some benefit in these patients and oral acyclovir was generally ineffective. Neovascular complications including retinal, disc, choroidal, and iris new vessels were common, requiring photocoagulation in five patients. Horseshoe tears developed in two patients in zones of uninvolved retina but retinal detachment did not occur. The etiology remains unknown, although it may represent either a localized ocular form of Behçet's disease or other systemic syndrome, infection with a herpes group virus other than zoster varicella virus, or a manifestation of an undefined infectious agent.

Mechanisms of maculopathy

This article will review the cellular constituents of the macula and speculate on their contribution to the pathogenesis of macular disease. The retinal pigment epithelium (RPE) has been implicated in senile macular degeneration (SMD). Over time, RPE dysfunction and death may result from the cumulative effect of light and free radical damage. Inherited metabolic abnormalities or the degree of uveal pigmentation could increase the RPE's susceptibility to environmental stress. In exudative SMD, the excessive production of extracellular matrix material by the RPE may contribute to sub-RPE neovascularization and disciform scar formation. Macular edema reflects a breakdown in the blood-retinal barrier. Inflammatory mediators produced in the anterior segment may cause aphakic cystoid macular edema (CME). Recent observations suggest that Müller cell dysfunction is important in CME. Vascular incompetence, as well as capillary occlusion characterize diabetic retinopathy. Angiogenic factors elaborated by ischemic retina are thought to be the stimulus for neovascularization. Diabetic tractional macular detachment results from neovascular proliferation on the partially detached vitreous. Posterior vitreous detachment predisposes to epiretinal gliosis. Endogenous infections and metastatic neoplasms have a predilection for the macula, reflecting the region's high blood flow.

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.