Subacute sclerosing panencephalitis manifesting as viral retinitis: clinical and histopathologic findings

Indocyanine green angiography reveals choroidal hypoperfusion in subacute sclerosing panencephalitis (SSPE)

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.

Optical Coherence Tomography Angiographic Follow-Up in a Case of Subacute Sclerosing Panencephalitis and Unilateral Necrotising Retinitis

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.

Macular Necrotizing Retinitis as a Presenting Feature of Atypical Fulminant SSPE: A Case Report

Purpose: To report ocular findings in a case of atypical fulminant SSPECase report: A 20-year-old male who came with macular necrotising retinitis in both his eyes in absence of any neurological feature. Within a week the patient developed dystonic posturing and seizures. CSF examination revealed raised measles antibody titres and EEG was suggestive of SSPE. The patient succumbed to the disease within 35 days of presentation.Conclusion: SSPE can rarely have a rapidly progressive downhill course without typical neurological features and ophthalmic features which appear to be more consistent may help in clinching the diagnosis in these cases.

History through the eyes of a pandemic

PURPOSE OF REVIEW

This review provides a historic perspective of the impact that major pandemics have had on human and their relationship with ophthalmology. The novel coronavirus epidemic is also analyzed, highlighting the relevance of the eye as a possible source of transmission, infection, and prognosis for the disease.

RESULTS

Smallpox is suspected to be present for more than 12 000 years. However, trachoma seems to be the first recorded ophthalmological infectious disease. The deadliest pandemics include the bubonic plague, smallpox, and Spanish flu. The CoVID-19 epidemic is still developing and measures need to be implemented to prevent further escalation of the crisis.

SUMMARY

Understanding the current facts in light of earlier historical evidence may help us prepare better to minimize the spread of infections in the future.

Subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE) is a slowly progressive brain disorder caused by mutant measles virus. SSPE affects younger age groups. SSPE incidence is proportional to that of measles. High-income countries have seen substantial decline in SSPE incidence following universal vaccination against measles. SSPE virus differs from wild measles virus. Measles virus genome recovered from the autopsied brain tissues demonstrates clustered mutations in virus genome particularly in the M gene. These mutations destroy the structure and functioning of the encoded proteins. Complete infectious virus particle has rarely been recovered from the brain. Human neurons lack required receptor for entry of measles virus inside the neurons. Recent in vitro studies suggest that mutations in F protein confer hyperfusogenic properties to measles virus facilitating transneuronal viral spread. The inflammatory response in the brain leads to extensive tissue damage. Clinically, SSPE is characterized by florid panencephalitis. Clinically, SSPE is characterized by cognitive decline, periodic myoclonus, gait abnormalities, vision loss, and ultimately to a vegetative state. Chorioretinitis is a common ocular abnormality. Electroencephalography (EEG) shows characteristic periodic discharges. Neuroimaging demonstrates periventricular white matter signal abnormalities. In advanced stages, there is marked cerebral atrophy. Definitive diagnosis requires demonstration of elevated measles antibody titers in cerebrospinal fluid (CSF). Many drugs have been used to stabilize the course of the disease but without evidence from randomized clinical trials. Six percent of patients may experience prolonged spontaneous remission. Fusion inhibitor peptide may, in the future, be exploited to treat SSPE. A universal vaccination against measles is the only proven way to tackle this menace currently.

Analysis of Progressive Ophthalmic Lesion in a Patient with Subacute Sclerosing Panencephalitis

Purpose

To evaluate the progressive lesions affecting the visual system in a patient with subacute sclerosing panencephalitis (SSPE).

Methods

The authors observed a 15-year-old boy with SSPE. Since the diagnosis was made before the appearance of ocular manifestations, the authors recorded the progressive ocular lesions using various ophthalmic examinations.

Results

The patient showed no ophthalmic abnormalities until he developed a left homonymous hemianopia with sudden bilateral disturbed visual acuity. Severe progressive macular lesions including a pigment epithelial window defect by fluorescein angiography, a marked decrease in foveal thickness by optical coherence tomography, and an extensive disorder mainly specific to cone cells in the central retina by electroretinography were demonstrated. Novel findings such as a transient relative afferent pupillary defect and an anterior uveitis were also observed.

Conclusions

Analyses over a long period of time showed progressive ophthalmic findings in a patient with SSPE.

BILATERAL SUBRETINAL FLUID AND RETINAL VASCULOPATHY ASSOCIATED WITH SUBACUTE SCLEROSING PANENCEPHALITIS

PURPOSE

To report a case of bilateral retinopathy associated with subacute sclerosing panencephalitis.

METHODS

History and clinical examination, fluorescein angiography, and optical coherence tomography.

RESULTS

We report a rare case of unilateral, followed by bilateral retinopathy, subretinal fluid, and vasculopathy in a young boy. History of missed measles vaccination, behavioral and neurologic symptoms, and electroencephalogram suggested a diagnosis of subacute sclerosing panencephalitis. Retinal imaging using optical coherence tomography was performed to document changes in the retinal microstructure through the natural course of the disease. Within 8 weeks, the changes progressed to retinal atrophy in both eyes.

CONCLUSION

The progressive course of retinitis associated with subacute sclerosing panencephalitis can be monitored on optical coherence tomography. Retinitis is subacute sclerosing panencephalitis rapidly progressive from the acute stage to the stage of atrophy, involving full thickness of the retina.

Blindness, dancing extremities, and corpus callosum and brain stem involvement: an unusual presentation of fulminant subacute sclerosing panencephalitis

A 4-year-old girl presented with acute visual loss followed 2 weeks later with loss of speech and audition, fulminant neuroregression, and choreo-athetoid movements of extremities. Fundus showed bilateral chorioretinitis. Electroencephalography showed periodic complexes. Measles antibody titers were elevated in both serum and cerebrospinal fluid, consistent with subacute sclerosing panencephalitis. Neuroimaging showed discontiguous involvement of splenium of the corpus callosum and ventral pons with sparing of cortical white matter. Our case highlights the atypical clinical and radiologic presentations of subacute sclerosing panencephalitis. Pediatricians need to be aware that necrotizing chorioretinitis in a child and/or atypical brain stem changes could be the heralding feature of this condition in endemic countries.

Unique optical coherence tomography findings in a case of macular retinitis caused by subacute sclerosing panencephalitis

BACKGROUND

Subacute sclerosing panencephalitis is a rare neurodegenerative disease. The ophthalmologic findings, typically necrotizing retinitis, often precede other neurologic signs and symptoms. Ocular findings are helpful for early diagnosis, but the findings of optical coherence tomography (OCT) images in an active phase of retinitis have never been reported. We report unique findings of OCT images in a case of subacute sclerosing panencephalitis.

PATIENT AND METHODS

A 13-year-old boy was referred to our hospital complaining of visual loss and other neurologic symptoms.

RESULTS

The fundus examination showed necrotizing retinitis. The OCT images showed empty spaces involving all layers of retina except the inner limiting membrane and hyperreflective lesion in inner retina. The diagnosis of subacute sclerosing panencephalitis was made from the blood and the spinal cerebral fluid test.

DISCUSSION

This is the first report on OCT images of necrotizing retinitis in an active stage of subacute sclerosing panencephalitis case. The unique findings of OCT images as in this case help to diagnose the rare devastating disease.

New aspects of viral necrotizing retinitis in subacute sclerosing panencephalitis with spectral-domain optical coherence tomography

PURPOSE

To report the clinical, angiographic, and tomographic features of an adult patient with bilateral occlusive vasculitis and necrotizing retinitis preceding the onset of subacute sclerosing panencephalitis by 3 years.

METHODS

Observational case report.

RESULTS

A 39-year-old white man presented with sudden onset of decreased vision in his left eye. The patient reported a history of right visual loss 3 years ago after an episode of retinal vasculitis of unknown origin. At presentation, left fundus examination showed sensory retinal detachment and retinal hemorrhages in the left macula. Fluorescein angiography revealed occlusive vasculitis. Two weeks later, several circumscribed lesions of necrotizing retinitis appeared in the macula and in the midperiphery after a centrifugal linear pattern from the optic nerve. Spectral-domain optical coherence tomography demonstrated focal areas of moth-eaten disorganization of the ganglion cell and nuclear layers with a spreading from the inner layers to the outer layers.

CONCLUSION

This unusual case of adult-onset subacute sclerosing panencephalitis may help improve our knowledge regarding the mechanism of retinal involvement in this disease. Clinical and tomographic findings suggest a continuous transneuronal spread of the measles virus from ganglion cells to the photoreceptor cells.

The eye in neurological disease

Neurological disease can involve the eye in many ways. Every structure--the conjunctiva, cornea, anterior chamber, iris, lens, vitreous humour, retina, choroid, and optic nerve--can be affected. In many cases, ocular involvement is the first manifestation of the underlying disease. In such cases, the ability of the physician to recognise the nature and significance of the ocular abnormality can lead to early diagnosis and successful treatment of the underlying condition. In other cases, recognition of the ocular abnormality can prevent permanent visual dysfunction.

Diagnostic dilemmas in fulminant subacute sclerosing panencephalitis (SSPE)

This report describes an eleven-year-old boy with atypical features of subacute sclerosing panencephalitis (SSPE), a rare complication of measles. He had only visual symptoms for 2 months followed by rapid neurological worsening to a vegetative state in 10 days. A diagnosis of SSPE was made based on the history of measles, characteristic ocular findings, compatible magnetic resonance imaging and electroencephalographic changes, and elevated ratio of cerebrospinal fluid to serum anti-measles antibody titers.

Acute multifocal placoid pigment epitheliopathy-like lesion as an early presentation of subacute sclerosing panencephalitis

PURPOSE

To report a case of acute multifocal placoid pigment epitheliopathy (AMPPE)-like lesion as an early presentation of subacute sclerosing panencephalitis (SSPE).

DESIGN

Observational case report.

METHODS

A 21-year-old woman presented with a profound loss of vision in the left eye. The initial clinical picture was characterized by a whitish infiltration of the macular area and papillary edema in the left eye. Six days later multiple chorioretinal infiltrations were present in the peripheral fundus of the left eye, which led to the diagnosis of AMPPE.

RESULTS

During the following year, a gradual change in her personality developed. The diagnosis of SSPE was made by cerebrospinal fluid examination. Her clinical condition deteriorated rapidly, and she died.

CONCLUSIONS

AMPPE can be accompanied by central nervous system involvement. We wish to emphasize the importance of considering the diagnosis of SSPE in cases of AMPPE.

Subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE) is a progressive neurological disorder of childhood and early adolescence. It is caused by persistent defective measles virus. Brain biopsies or postmortem histopathological examination show evidence of astrogliosis, neuronal loss, degeneration of dendrites, demyelination, neurofibrillary tangles, and infiltration of inflammatory cells. Patients usually have behavioral changes, myoclonus, dementia, visual disturbances, and pyramidal and extrapyramidal signs. The disease has a gradual progressive course leading to death within 1-3 years. The diagnosis is based upon characteristic clinical manifestations, the presence of characteristic periodic EEG discharges, and demonstration of raised antibody titre against measles in the plasma and cerebrospinal fluid. Treatment for SSPE is still undetermined. A combination of oral isoprinosine (Inosiplex) and intraventricular interferon alfa appears to be the best effective treatment. Patients responding to treatment need to receive it life long. Effective immunisation against measles is the only solution presently available to the problem of this dreaded disease.

Measles-mumps-rubella vaccine and autistic spectrum disorder: report from the New Challenges in Childhood Immunizations Conference convened in Oak Brook, Illinois, June 12-13, 2000

BACKGROUND

Parents and physicians are understandably concerned about the causes and treatment of autism, a devastating disease that affects the entire family. Although much has been learned about autism, there are many gaps in our knowledge about what causes the disorder and how it can be prevented. Autistic symptoms occur along a spectrum, often referred to as autistic spectrum disorder (ASD). Concern has been raised about a possible association between measles-mumps-rubella (MMR) vaccine and inflammatory bowel disease (IBD) and ASD, especially autism with regression. Also, increased requests for educational services related to ASD have raised concerns about possible increases in the incidence of ASD.

METHODS

On June 12-13, 2000, the American Academy of Pediatrics (AAP) convened a conference titled "New Challenges in Childhood Immunizations" in Oak Brook, Illinois. At this conference, parents, practitioners, and scientists presented information and research on MMR vaccine and ASD. Attendees included representatives from select AAP committees and sections as well as federal and other organizations that address related issues. The multidisciplinary panel of experts reviewed data on what is known about the pathogenesis, epidemiology, and genetics of ASD and the available data on hypothesized associations with IBD, measles, and MMR vaccine. Supplemental information was requested from authors who have proposed the hypotheses and other experts in relevant areas.

RESULTS

Autism is a complex disorder of uncertain and probably multiple etiologies. Genetic predisposition to ASD may involve as many as 10 genes. Many experts believe that the abnormal brain development in autism occurs before 30 weeks' gestation in most instances. In utero rubella is a known cause of autism. Animal model data support the biologic plausibility that exposure to yet unrecognized infectious or other environmental agents could cause ASD. Several factors may contribute to apparent increases in incidence of ASD in recent years. Most data indicate increased recognition and reporting as primary factors, but the epidemiologic data are insufficient to determine if there has been a true increase in the incidence of ASD. Increased reporting of ASD in recent years has occurred long after the introduction of MMR vaccine in the United States in 1971 and widespread use of this vaccine in the 1970s for routine immunization of children at 12 to 15 months of age. Appropriate detailed studies are needed to define the true incidence and prevalence of ASD. Epidemiologic studies in Europe indicate no association between MMR vaccine and ASD. Some children with ASD have gastrointestinal symptoms, but an increased rate of any specific gastrointestinal disorder in children with ASD has not been established. Studies to detect evidence of measles virus in intestinal tissue specimens from patients with IBD or autism with gastrointestinal symptoms have not used uniform techniques. Several laboratories have found no evidence of measles viruses in tissue specimens from patients with IBD, but 2 groups have found evidence of measles virus using different techniques. A group that found evidence of measles virus in affected tissue specimens from patients with IBD has also reported detecting portions of measles virus in peripheral blood lymphocytes and intestinal tissue specimens from patients with autism and gastrointestinal disorders. Finding a portion of a virus using molecular techniques does not constitute evidence for a causal relationship, because some viruses persist in unaffected hosts. Additional controlled studies in several laboratories are needed to determine if portions of measles virus persist in intestinal and other tissues of people with and without gastrointestinal disease and/or ASD.

CONCLUSIONS

Although the possible association with MMR vaccine has received much public and political attention and there are many who have derived their own conclusions based on personal experiences, the available evidence does not support the hypothesis that MMR vaccine causes autism or associated disorders or IBD. Separate administration of measles, mumps, and rubella vaccines to children provides no benefit over administration of the combination MMR vaccine and would result in delayed or missed immunizations. Pediatricians need to work with families to ensure that children are protected early in the second year of life from these preventable diseases. Continued scientific efforts need to be directed to the identification of the causes of ASD.