Headache as a first manifestation of Vogt-Koyanagi-Harada disease

Precise, simplified diagnostic criteria and optimised management of initial-onset Vogt-Koyanagi-Harada disease: an updated review

Vogt-Koyanagi-Harada (VKH) disease is a primary autoimmune stromal choroiditis. This review aimed to provide a novel perspective of the disease. We took into account recent developments in the understanding of the disease and crucial progress in investigational modalities of the choroid, which has led to new, simpler diagnostic criteria. We analysed recent novel notions in the literature and new diagnostic tools for VKH. We identified the following updates for VKH disease: (1) A crucial differentiation between the acute initial-onset and the chronic forms of the disease; (2) the integration of new, precise imaging methods to assess choroidal inflammation; (3) the promotion of simplified, more reliable diagnostic criteria for acute initial-onset of the disease, based on the sine qua non presence of diffuse choroiditis, detected with indocyanine green angiography (ICGA) and/or Enhanced Depth Imaging OCT (EDI-OCT); and (4) treatment optimisation through early, vigorous, sustained corticosteroid and nonsteroidal immunosuppression, as the first line of treatment for initial-onset VKH disease, and monitoring subclinical choroidal inflammation during follow-ups. Several studies have shown that most patients could discontinue treatment without an inflammation relapse. ICGA and EDI-OCT represented the methods of choice for precisely monitoring disease evolution. Simplified, precise, new diagnostic criteria allow early diagnosis of VKH. In VKH disease, inflammation exclusively originates in the choroidal stroma. Therefore, in many cases, early, sustained treatment, with dual corticosteroid and nonsteroidal immunosuppressive therapy can result in full "healing", which obviates chronic, uncontrolled, subclinical choroidal inflammation.

Reappraisal of the management of Vogt-Koyanagi-Harada disease: sunset glow fundus is no more a fatality

Purpose

Vogt–Koyanagi–Harada (VKH) disease is a primary autoimmune stromal choroiditis. Aim of the study was to gather a body of evidence from the literature and from experts that systemic corticosteroid combined with non-steroidal immunosuppressive therapy should become the standard of care in initial-onset VKH disease.

Methods

Literature was reviewed and leading experts in VKH were consulted in different parts of the world in order to put forward a consensus attitude in the management of initial-onset VKH disease.

Results

There was a substantial body of evidence in the literature that early aggressive and sustained corticosteroid and non-steroidal immunosuppressive therapy in initial-onset VKH disease allows to achieve full control of choroidal inflammation, eliminating any subclinical choroidal inflammation, and substantially reduces recurrences with improvement of anatomical and functional outcomes. This was in agreement with experts’ opinion and practice. ICGA was the method of choice to monitor disease evolution.

Conclusion

Since the choroidal space is easily accessible to systemic therapy and because inflammation in VKH disease is exclusively originating from the choroidal stroma, early and sustained treatment right at the onset of the disease process with dual corticosteroid and non-steroidal immunosuppressive therapy can result in full “healing” in many cases preventing sunset glow fundus which results from depigmentation from chronic uncontrolled inflammation.

Unusual Case of Vogt-Koyanagi-Harada Syndrome Presenting as Non-specific Headache

Vogt-Koyanagi-Harada syndrome (VKH) is a bilateral intraocular granulomatous panuveitis which is frequently associated with systemic manifestations such as meningismus, tinnitus, poliosis and vitiligo of autoimmune aetiology. Headache by itself, does not fulfill the diagnostic criteria and is insufficient for the diagnosis. A 22-year-old male presented with a 10 day history of headache, followed by decreased vision in both eyes. Slit lamp biomicroscopy revealed sluggishly reactive pupils with anterior uveitis, mild vitritis and hyperaemic discs with bilateral exudative retinal detachments. All uveitis workups were negative. Follow up of three years revealed no neurological or auditory symptoms. Headache alone, followed by decreased vision, before the onset of neurological and auditory symptoms, can be an initial presentation of Vogt-Koyanagi-Harada (VKH) syndrome. VKH should be considered in the differential diagnosis of atypical presentations of headache.

Headache as an initial manifestation of Vogt-Koyanagi-Harada disease

A 29 year-old healthy Saudi female presented with a 1 week history of headache followed by decreased vision in both eyes. Biomicroscopy revealed anterior uveitis without hypopyon, posterior synechia or keratic precipitate. Fundus examinations were remarkable for serous retinal detachment and hyperemic discs. Fundus fluorescein angiogram showed a hot disc with multiple pinpoint leakage in both eyes. CT scan and MRI were normal, all uveitis workups were negative. Five months later, the patient presented with complete criteria of Vogt-Koyanagi-Harada disease including a 2 weeks history of tinnitus, alopecia, poliosis and vitiligo. Headache alone followed by decreased vision before the onset of neurological and auditory symptoms can be an initial presentation of VKH disease. VKH should be considered in the differential diagnosis of atypical presentation of symptoms.

Primary headache associated with sexual activity: case report

OBJECTIVES

To present a rare case of primary headache associated with sexual activity.

CLINICAL PRESENTATION AND INTERVENTION

A 48-year-old man presented with a severe headache during sexual intercourse, particularly at the time of orgasm. A diagnosis of type 2 primary headache associated with sexual activity was made, and he was started on indomethacin 25 mg to be taken 30 min before intercourse and propranolol 40 mg twice a day, following which he noted a dramatic improvement within in a week.

CONCLUSIONS

The case highlights the importance of paying attention to the differential diagnosis. For this patient, prophylactic treatment with beta-blockers and/or preemptive therapy with indomethacin was successful.