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Agarwal A, Majumder PD. Indocyanine green angiography reveals choroidal hypoperfusion in subacute sclerosing panencephalitis (SSPE). Eur J Ophthalmol 2024:11206721241273563. [PMID: 39150819 DOI: 10.1177/11206721241273563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024]
Abstract
We report the choroidal findings on indocyanine green angiography (ICGA) in two cases of subacute sclerosing panencephalitis (SSPE). The two immunocompetent patients (31-year-old and 30-year-old Asian Indian males) presented with acute-onset rapidly progressing vision loss with findings of necrotizing retinitis involving the central macula. Both patients tested negative for serological evidence of herpes or varicella, and toxoplasma antibodies. The patients demonstrated high serum and cerebrospinal fluid titers of anti-measles antibody (and abnormal electroencephalogram in one patient) leading to the diagnosis of SSPE. ICGA of both patients revealed distinct "dark dots" which showed hypofluorescence in the early and late phases suggestive of choroidal involvement/hypoperfusion. Choroidal involvement in SSPE has not been evaluated before and must be considered in the pathological manifestations of the disease.
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Affiliation(s)
- Aniruddha Agarwal
- The Eye Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates, Abu Dhabi, UAE
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
- Department of Ophthalmology, Maastricht University Medical Center+, Maastricht, The Netherlands
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Köksaldı S, Ala RT, Oztura I, Emirbayer E, Akdal G, Emre S, Tugal-Tutkun I, Saatci AO. Optical Coherence Tomography Angiographic Follow-Up in a Case of Subacute Sclerosing Panencephalitis and Unilateral Necrotising Retinitis. Neuroophthalmology 2023; 48:142-151. [PMID: 38487359 PMCID: PMC10936593 DOI: 10.1080/01658107.2023.2284914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/31/2023] [Indexed: 03/17/2024] Open
Abstract
We present a 20-year-old woman who was diagnosed with subacute sclerosing panencephalitis (SSPE) 20 months after presenting with unilateral retinitis. At presentation, the patient had two inferotemporal macular lesions in her left eye. Corresponding to these areas, optical coherence tomography (OCT) showed hyporeflective spaces with loss of nearly all of the retinal layers. OCT-angiography (OCTA) demonstrated some flow deficit areas with a reduction in the vessel density. Her serum measles antibody titre was high (IgG >5000.0 mIU/ml). Twenty months later the macular lesions had diminished in size, and there was some focal retinal thinning with interruption of the ellipsoid zone. OCTA showed that the flow deficit areas were diminished in size together with the relatively improved perfusion density. Neurological examination disclosed myoclonic jerks. Neuropsychological assessment demonstrated impaired executive function, attention, and narrowed lexical fluency. Measles IgG antibody was high in the cerebrospinal fluid (>230.0 U/ml). Brain magnetic resonance imaging demonstrated bilateral, non-specific, small foci of T2 hyperintensity in the frontoparietal subcortical white matter and centrum semiovale. The present case is the first where OCTA findings of SSPE-related retinal lesions have been described.
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Affiliation(s)
- Seher Köksaldı
- Department of Ophthalmology, Dokuz Eylul University, Izmir, Turkey
| | - Rahmi Tumay Ala
- Department of Neurology, Dokuz Eylul University, Izmir, Turkey
| | - Ibrahim Oztura
- Department of Neurology, Dokuz Eylul University, Izmir, Turkey
| | - Emre Emirbayer
- Department of Neurology, Dokuz Eylul University, Izmir, Turkey
| | - Gulden Akdal
- Department of Neurology, Dokuz Eylul University, Izmir, Turkey
| | - Sinan Emre
- Department of Ophthalmology, Batıgöz Private Hospital, Izmir, Turkey
| | | | - Ali Osman Saatci
- Department of Ophthalmology, Dokuz Eylul University, Izmir, Turkey
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Steptoe PJ, Pearce I, Beare NAV, Sreekantam S, Mohammed BR, Barry RJ, Steeples LR, Denniston AK, Murray PI. Proposing a Neurotropic Etiology for Acute Posterior Multifocal Placoid Pigment Epitheliopathy and Relentless Placoid Chorioretinitis. FRONTIERS IN OPHTHALMOLOGY 2022; 1:802962. [PMID: 38983970 PMCID: PMC11182168 DOI: 10.3389/fopht.2021.802962] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/20/2021] [Indexed: 07/11/2024]
Abstract
Purpose To reassess the underlying pathophysiology of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) and relentless placoid chorioretinitis (RPC) through comparison with the non-inoculated eye of the von Szily animal model of neurotropic viral retinal infection. Methods Narrative review. Results Literature reports of isolated neurotropic viral entities and rising serological viral titers in APMPPE after presentation support a potential direct infective etiology. In general, viral transport along axons results in mitochondrial stasis and disruption of axoplasmic flow. Clinical manifestations of axoplasmic flow disruption in APMPPE/RPC may signify the passage of virus along the neuronal pathway. From a case series of 11 patients, we demonstrate a timely, spatial, and proportional association of optic disc swelling with APMPPE lesion occurrence. Signs within the inner retina appear to precede outer retinal lesions; and acute areas of outer nuclear layer (ONL) hyperreflectivity appear to be the result of coalescence of multiple hyperreflective foci resembling axonal spheroids (which occur as a consequence of axoplasmic disruption) and follow the Henle fiber layer neurons. Underlying areas of retinal pigment epithelium (RPE) hyper-autofluorescence follow ONL hyperreflectivity and may signify localized infection. Areas of apparent choriocapillaris hypoperfusion mirror areas of RPE/Bruch's membrane separation and appear secondary to tractional forces above. Increases in choroidal thickness with lesion occurrence and focal areas of choriocapillaris hypoperfusion are observed in both APMPPE/RPC and the von Szily model. Conclusions The neurotrophic infection model provides significant advantages over the existing primary choriocapillaris ischemia hypothesis to account for the range of imaging signs observed in APMPPE and RPC.
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Affiliation(s)
- Paul J Steptoe
- Princess Alexandra Eye Pavilion, Edinburgh, United Kingdom
| | - Ian Pearce
- St. Paul's Eye Unit, Liverpool University Hospitals National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom
| | - Nicholas A V Beare
- St. Paul's Eye Unit, Liverpool University Hospitals National Health Service (NHS) Foundation Trust, Liverpool, United Kingdom
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | | | | | - Robert J Barry
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Laura R Steeples
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Alastair K Denniston
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- Ophthalmology Department, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Centre for Rare Diseases, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Philip I Murray
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Saleh M. [Placoid pigment epitheliopathy and serpiginous choroiditis]. J Fr Ophtalmol 2020; 43:243-255. [PMID: 32007311 DOI: 10.1016/j.jfo.2019.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 11/19/2022]
Abstract
Placoid pigment epitheliopathy and serpiginous choroiditis are among the white dot retinal syndromes and possess similarities that can cause confusion between these two diseases. However, they are very different in terms of their progression and prognosis, which requires a diagnosis of certainty in order to better manage the patients with the diseases and identify potentially serious progressive complications. The clinical presentation, results of testing, differential diagnoses and treatment of these two pathologies are discussed in this article.
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Affiliation(s)
- M Saleh
- Ophthalmology department, Besançon University Regional Medical Centre, 3, boulevard Fleming, 25030 Besançon, France.
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Saleh M. Placoid pigment epitheliopathy and serpiginous choroiditis. J Fr Ophtalmol 2020; 43:e55-e66. [PMID: 31932062 DOI: 10.1016/j.jfo.2019.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/14/2019] [Accepted: 12/10/2019] [Indexed: 12/17/2022]
Abstract
Placoid pigment epitheliopathy and serpiginous choroiditis are among the white dot retinal syndromes and possess similarities that can cause confusion between these two diseases. However, they are very different in terms of their progression and prognosis, which requires a diagnosis of certainty in order to better manage the patients with the diseases and identify potentially serious progressive complications. The clinical presentation, results of testing, differential diagnoses and treatment of these two pathologies are discussed in this article.
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Affiliation(s)
- M Saleh
- Ophthalmology Department, Besançon University Regional Medical Center, 3, boulevard Alexandre-Fleming, 25030 Besançon, France.
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Fatal Ischemic Stroke Complicating Acute Multifocal Placoid Pigment Epitheliopathy. J Neuroophthalmol 2014; 34:10-5. [DOI: 10.1097/wno.0b013e318294a4b0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Optic neuritis and rapidly progressive necrotizing retinitis as the initial signs of subacute sclerosing panencephalitis: a case report with clinical and histopathologic findings. Int Ophthalmol 2014; 34:983-7. [DOI: 10.1007/s10792-014-9914-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 01/28/2014] [Indexed: 10/25/2022]
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Oleszczuk JD, Saeed MU. Neurological symptoms associated with acute multifocal placoid pigment epitheliopathy: treatment dilemma and diagnostic issues. Semin Ophthalmol 2013; 30:238-40. [PMID: 24175642 DOI: 10.3109/08820538.2013.839810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Acute multifocal placoid pigment epitheliopathy (AMPPE) is thought to be caused by vasculitis of the choroid. Central nervous system involvement is rare. We report a case of a 28-year-old male who developed blurred vision (6/12 OD, 6/24 OS). Past medical history involved non-specific viral meningitis treated with intravenous antibiotics and antivirals. Subsequently, the patient complained of recurrent headaches. Based on typical clinical findings and fluorescein angiogram, he was diagnosed with AMPPE. Visual disturbance resolved without any systemic treatment. Six months later, visual symptoms recurred and resolved spontaneously, but his headache continued. A few months later, the patient developed acute progressive neurological signs and symptoms necessitating inpatient admission. Lacunar infarcts in the CNS were found, which had not been noted in previous neuro-imaging studies. Cerebral vasculitis associated with AMPPE was diagnosed and treated with systemic steroids and immune suppression. Currently, the patient remains asymptomatic under joined care of an ophthalmologist and a neurologist.
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Serdaroğlu A, Gücüyener K, Dursun I, Aydin K, Okuyaz C, Subaşi M, Or M, Ozkan B. Macular Retinitis as a First Sign of Subacute Sclerosing Panencephalitis: The Importance of Early Diagnosis. Ocul Immunol Inflamm 2009; 13:405-10. [PMID: 16419428 DOI: 10.1080/09273940490912335] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Subacute sclerosing panencephalitis (SSPE) is a subacute inflammatory and neurodegenerative encephalitis related to the measles (rubeola) virus and usually affecting children and young adults. The overwhelming majority of cases follow a progressive downhill course leading to death, although there have been a few case reports of patients who have apparently gone into remission. Ocular changes occur in up to 50% of SSPE cases. Visual complaints, if present, generally antedate the onset of neurological symptoms by a few weeks or months. Here, we report two cases of SSPE presenting with ocular findings and their prognoses. METHODS Case reports. In the first case, a 17-year-old male presenting with macular retinitis, the macular findings were mistaken for a heredodegenerative disorder and diagnosis was postponed until neurological findings took place. He died six months after the appearance of his first ophthalmic symptoms despite intravenous immune globulin and isoprinosine therapy. The second case was a 14-year-old male, who presented with only ophthalmological complaints. His diagnosis was based on both ophthalmological findings and high doses of measles IgG in the cerebrospinal fluid (CSF); isoprinosine and intramuscular beta-interferon therapy was started before the onset of neurological findings and in the follow-up time of about 18 months, neurological findings consistent with SSPE did not develop. RESULTS The characteristic finding of macular retinitis in SSPE patients is rapid recovery in about one month without therapy. After improvement, neurological findings take place. Once suspected, the diagnosis of SSPE is easily established by the demonstration of high levels of measles antibody in the serum and CSF. Early diagnosis can be made with typical ocular findings and high IgG titers for rubeola in CSF. CONCLUSION We suppose that ophthalmic manifestations, especially macular retinitis, may be useful in the diagnosis and management of SSPE cases with elevated IgG titers for rubeola in CSF. The typical clinical findings must be familiar to every ophthalmologist so that diagnostic pitfalls can be prevented and early therapy started. It may be discussed if early diagnosis and therapy will be possible before neurological signs appear, the prognosis of this relentless disease may show a more favorable course.
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Affiliation(s)
- A Serdaroğlu
- Department of Pediatrics, Faculty of Medicine, Gazi University, Ankara, Turkey
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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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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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Salehi HR, Delgado E, Wolf SM, McGoldrick PE, Moshé SL. Subacute sclerosing panencephalitis with atypical features. Pediatr Neurol 2005; 33:280-2. [PMID: 16194728 DOI: 10.1016/j.pediatrneurol.2005.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2005] [Accepted: 04/04/2005] [Indexed: 11/29/2022]
Abstract
The incidence of subacute sclerosing panencephalitis may be rising. This report describes three patients identified in New York City with atypical features including age of onset, prolonged prodrome, and lack of specific electroencephalographic changes. The diagnosis was confirmed with the identification of measles antibodies in the cerebrospinal fluid. Awareness of the possibility that the clinical presentation of subacute sclerosing panencephalitis may be changing may increase its timely diagnosis.
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Affiliation(s)
- Hamid R Salehi
- Department of Neurology, Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10461, USA
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Abstract
Morbilliviruses are a group of viruses that belong to the family Paramyxoviridae. The most instantly recognizable member is measles virus (MV) and individuals acutely infected with the virus exhibit a wide range of clinical symptoms ranging from a characteristic mild self-limiting infection to death. Canine distemper virus (CDV) and rinderpest virus (RPV) cause a similar but distinctive pathology in dogs and cattle, respectively, and these, alongside experimental MV infection of primates, have been useful models for MV pathogenesis. Traditionally, viruses were identified because a distinctive disease was observed in man or animals; an infectious agent was subsequently isolated, cultured, and this could be used to recapitulate the disease in an experimentally infected host. Thus, satisfying Koch's postulates has been the norm. More recently, particularly due to the advent of exceedingly sensitive molecular biological assays, many researchers have looked for infectious agents in disease conditions for which a viral aetiology has not been previously established. For these cases, the modified Koch's postulates of Bradford Hill have been developed as criteria to link a virus to a specific disease. Only in a few cases have these conditions been fulfilled. Therefore, many viruses have over the years been definitely and tentatively linked to human diseases and in this respect the morbilliviruses are no different. In this review, human diseases associated with morbillivirus infection have been grouped into three broad categories: (1) those which are definitely caused by the infection; (2) those which may be exacerbated or facilitated by an infection; and (3) those which currently have limited, weak, unsubstantiated or no credible scientific evidence to support any link to a morbillivirus. Thus, an attempt has been made to clarify the published data and separate human diseases actually linked to morbilliviruses from those that are merely anecdotally associated.
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Affiliation(s)
- Bertus K Rima
- School of Biomedical Sciences and Centre for Cancer Research and Cell Biology, The Queen's University of Belfast, UK.
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