Mitoxantrone therapy for acute posterior multifocal placoid pigment epitheliopathy with cerebral vasculitis

Neurological complications of acute multifocal placoid pigment epitheliopathy

Acute multifocal placoid pigment epitheliopathy (AMPPE) is an autoimmune chorioretinal disease that can be complicated by neurological involvement. There is limited information on this potentially treatable condition in the neurological literature. The objective of this patient series is to describe the neurological complications of AMPPE. We retrospectively identified patients with neurological complications of AMPPE seen at Auckland Hospital between 2008 and 2013 and summarised cases in the literature between 1976 and 2013. We identified five patients with neurological complications of AMPPE at Auckland Hospital and 47 reported patients. These patients demonstrated a spectrum of neurological involvement including isolated headache, stroke or transient ischaemic attack, seizures, venous sinus thrombosis, optic neuritis, sensorineural hearing loss and peripheral vestibular disorder. We propose criteria to define AMPPE with neurological complications. A cerebrospinal fluid (CSF) lymphocytosis in a patient with isolated headache may predict the development of cerebrovascular complications of AMPPE. Patients with cerebrovascular complications of AMPPE have a poor prognosis with high rates of death and neurological disability among survivors. Predictors of poor outcome in those who develop neurological complications of AMPPE are a relapsing course, generalised seizures and multifocal infarction on MRI. All patients with neurological complications of AMPPE, including headache alone, should be investigated with an MRI brain and CSF examination. Patients with focal neurological symptoms should receive intravenous (IV) methylprednisolone followed by a tapering course of oral steroids for at least 3months. Patients with AMPPE and an isolated headache with a CSF pleocytosis should be treated with oral steroids.

Ocular outcome and frequency of neurological manifestations in patients with acute posterior multifocal placoid pigment epitheliopathy (APMPPE)

PURPOSE

The purpose of this study was to describe the visual prognosis as well as the frequency and clinical severity of central nervous system involvement in all acute posterior multifocal placoid pigment epitheliopathy (APMPPE) patients of one centre.

METHODS

A retrospective database review of all patients and a prospective clinical, ophthalmological and neurological follow-up, if possible, were conducted.

RESULTS

Eighteen patients with APMPPE were included with a mean follow-up of 17.1 months. Thirteen patients participated in a follow-up exam. Visual acuity improved in 9 of 18 patients to a mean of 0.17 log minimum angle of resolution (MAR) in the worse eye and remained stable in eight patients (mean, 0.03 logMAR). In the majority of patients, the 30° static perimetry improved at follow-up compared to the initial exams. Still, in up to 50 to 60 %, small visual field defects persisted. Overall, 11 patients (61 %) showed neurologic symptoms of varying severity. The most common neurological symptom was headache in nine (50 %) patients. Other symptoms included paraesthesias, psychosis, vertigo, and, as the most severe complication, stroke due to cerebral vasculitis. Fifteen patients were treated with systemic corticosteroids.

CONCLUSIONS

Visual prognosis is good in patients with APMPPE, but visual field defects may remain. Neurological signs and symptoms, especially headaches, are frequent in APMPPE and should be taken seriously. Adequate investigations including MRI and CSF examination should be initiated in these patients.

Recurring meningoencephalitis in sinusitis-associated acute posterior multifocal placoid pigment epitheliopathy under prednisone tapering

The authors describe a case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with recurrent neurological complications. A 24-year-old man experienced subacute bilateral visual loss. Based on the characteristic findings in funduscopy and fluorescin angiography and after the exclusion of the differential diagnoses, APMPPE was diagnosed. During the course of the disease recurrent episodes of meningitis and encephalitis occurred when tapering of prednisone was attempted. Secondary to encephalitic lesions, the patient developed partial epileptic seizures, which made an anticonvulsive medication necessary. The authors considered a chronic sinusitis to be an aetiological factor of the underlying autoimmune process. Due to the complicated course of APMPPE, they decided to start long-term immunosuppressive therapy with azathioprine under which the patient remained stable and prednisone could be tapered successfully. Neurological complications of APMPPE are rare. Nevertheless, this case demonstrates that long-term immunosuppressive treatment might be necessary to prevent recurrent neurological complications in some cases.