Unilateral acute maculopathy associated with adult onset hand, foot and mouth disease: case report and review of literature

UNILATERAL ACUTE IDIOPATHIC MACULOPATHY IN A PATIENT WITH HAND-FOOT-MOUTH DISEASE: A CASE REPORT

PURPOSE

To demonstrate a rare cause of acute, focal chorioretinitis.

METHODS

Review of slit-lamp fundoscopy, color fundus photography, spectral-domain optical coherence tomography, and fluorescein angiography.

RESULTS

Slit-lamp examination revealed parafoveal microaneurysms, parafoveal intraretinal hemorrhages, and outer segment irregularity in the left eye. Fundus photographs demonstrated retinal hemorrhages and a greyish-whitish sheen in the central parafoveal area. Optical coherence tomography was notable for a small pocket of outer segment and retinal pigment epithelium disruption and irregularity in the central foveal area of the left eye. Fluorescein angiography revealed increased focal macular leakage within a larger central area of leakage and staining.

CONCLUSION

Unilateral acute idiopathic maculopathy and, specifically, coxsackievirus-related chorioretinitis should be considered in the differential diagnosis of atypical maculopathy.

Hand, Foot, and Mouth Disease: A Narrative Review

BACKGROUND

Hand, foot, and mouth disease is a common viral disease in childhood. Because the disease has the potential to reach epidemic levels and mortality is high in some countries, early recognition of this disease is of paramount importance.

OBJECTIVE

This purpose of this article is to familiarize pediatricians with the clinical manifestations and management of hand, foot, and mouth disease.

METHODS

A search was conducted in February 2022 in PubMed Clinical Queries using the key term "hand, foot, and mouth disease". The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in English were included in this review.

RESULTS

Hand, foot, and mouth disease is characterized by a painful oral enanthem and asymptomatic exanthem on the palms and soles. Children younger than 5 years are most commonly affected. Hand, foot, and mouth disease caused by enterovirus A71 is more severe and has a higher rate of complications than that attributed to other viruses such as coxsackievirus A16. Circulatory failure secondary to myocardial impairment and neurogenic pulmonary edema secondary to brainstem damage are the main causes of death. Fortunately, the disease is usually benign and resolves in 7 to10 days without sequelae. Given the self-limited nature of most cases, treatment is mainly symptomatic and supportive. Intravenous immunoglobulin should be considered for the treatment of severe/complicated hand, foot, and mouth disease and has been recommended by several national and international guideline committees. Currently, there are no specific antiviral agents approved for the treatment of the disease. Drugs such as ribavirin, suramin, mulberroside C, aminothiazole analogs, and sertraline have emerged as potential candidates for the treatment of hand, foot, and mouth disease. Vaccination of susceptible individuals in high-risk areas and good personal hygiene are important preventative measures to combat the disease.

CONCLUSION

Familiarity of the disease including its atypical manifestations is crucial so that a correct diagnosis can be made, and appropriate treatment initiated. A timely diagnosis can help avoid contact with the affected individual and decrease the risk of an outbreak.

Case Report: Improved Choroidal Circulation in a Patient with Unilateral Acute Idiopathic Maculopathy

SIGNIFICANCE

Unilateral acute idiopathic maculopathy is a rare retinochoroidal disorder, the cause of which is unknown. Multimodal retinal imaging obtained in this case suggests that the cause of unilateral acute idiopathic maculopathy is impaired choroidal circulation.

PURPOSE

To report a patient with unilateral acute idiopathic maculopathy who showed improvement of choroidal circulation over time in optical coherence tomography angiography images.

CASE REPORT

A 33-year-old female with a prodromal flu-like illness noticed a sudden central visual field abnormality in the right eye. Five days after the onset, best corrected visual acuity (BCVA) was 0.15 in the right eye. Fundus photography showed a yellowish lesion at the macula in the right eye. Optical coherence tomography showed a blurred ellipsoid zone and thickened retinal pigment epithelium at the fovea and disrupted/blurred ellipsoid zone and retinal pigment epithelium at the parafovea. Optical coherence tomography angiography segmentation of the choriocapillaris revealed hypo-intense region at the fovea with hyper-intense region surrounding it. One week after the onset, BCVA was improved from 0.15 to 2.0 in the right eye. Furthermore, the yellowish macula lesion shrank, and outer retinal layers showed improvement in optical coherence tomography. optical coherence tomography angiography showed reduction of hypo-intense region and enlargement of hyper-intense region. About one year after the onset, the yellowish lesion was faded. Optical coherence tomography revealed an almost normal ellipsoid zone, but a thickened interdigitation zone. optical coherence tomography angiography also revealed apparent hyper-intense instead of hypo-intense region and increased choroidal blood flow.

CONCLUSIONS

The current patient showed gradual recovery of choroidal circulation as well as outer retinal layer morphology one year after onset of unilateral acute idiopathic maculopathy. optical coherence tomography angiography findings indicated that the primary cause of unilateral acute idiopathic maculopathy was impaired choroidal circulation, and choroidal vessels improved morphologically over the disease course.

ACUTE IDIOPATHIC MACULOPATHY: A Proposed Disease Staging Based on Multimodal Imaging

PURPOSE

To describe the clinical course and the multimodal imaging of acute idiopathic maculopathy.

METHODS

Medical records and multimodal imaging including color fundus photography, optical coherence tomography, and fundus autofluorescence were retrospectively reviewed. Recognition of the fundus autofluorescence patterns and their relationship with the disease duration, best-corrected visual acuity, and optical coherence tomography features represented the main outcome measures.

RESULTS

Seventeen eyes of 16 patients (7 women; mean age 29.9 years) with a mean follow-up of 23.9 months were included. The mean best-corrected visual acuity at presentation was 0.63 ± 0.54 logarithm of the minimum angle of resolution (Snellen equivalent, 20/85). All but one patient had the best-corrected visual acuity recovery to 20/20. Four sequential patterns of fundus autofluorescence corresponding to 4 proposed stages of disease were observed. Patterns 1 (central hypoautofluorescence with surrounding hyperautofluorescence) and 2 (stippled hyperautofluorescence and hypoautofluorescence) were found at presentation. Patterns 3 (central hyperautofluorescence surrounded by hypoautofluorescence) and 4 (hypoautofluorescence) were observed during the disease course and/or at the last follow-up visit. Duration of the disease was significantly different between patterns at baseline and last visit. Pattern 1 significantly related to the presence of subretinal detachment (Fisher's exact test; P =0.003) on optical coherence tomography in comparison with Pattern 2. Pattern 4 showed unique homogeneously decreased autofluorescence with corresponding attenuation of retinal pigment epithelium and restored outer retinal layers on optical coherence tomography.

CONCLUSION

A sequential disease staging based on multimodal imaging for acute idiopathic maculopathy is proposed. The recognition of the observed imaging patterns may help clinicians in the correct diagnosis and patient counseling.

ACUTE IDIOPATHIC MACULOPATHY COMPLICATED BY CHOROIDAL NEOVASCULARIZATION: NEW INSIGHTS INTO MULTIMODAL RETINAL IMAGING

PURPOSE

To report a case of acute idiopathic maculopathy complicated by choroidal neovascularization (CNV) in which multimodal imaging was used to confirm the presence of CNV and follow the response to anti-vascular endothelial growth factor treatment.

METHODS

A 39-year-old man was referred to our clinic for the evaluation of maculopathy in the right eye. Multimodal imaging was performed including fundus photography, fundus autofluorescence, infrared fundus reflectance (IR), optical coherence tomography, fluorescein angiography, indocyanine green angiography, and optical coherence tomography angiography.

RESULTS

On the first examination, best-corrected visual acuity was 20/63 in the right eye and 20/20 in the left eye. A diagnosis of acute idiopathic maculopathy in the right eye was made on the basis of clinical presentation and multimodal imaging. After 3 months, best-corrected visual acuity had decreased to 20/100. Fluorescein angiography and indocyanine green angiography suggested the presence of a CNV. Optical coherence tomography angiography confirmed the presence of the CNV and well outlined the extension of the neovascular network. The patient underwent 2 monthly bevacizumab intravitreal injections. One month after the second injection, best-corrected visual acuity improved to 20/25, and optical coherence tomography angiography showed regression of the neovascular network. Best-corrected visual acuity remained stable during 20 months of follow-up.

CONCLUSION

Our case reports the uncommon association of acute idiopathic maculopathy complicated by CNV. Multiimaging approach allowed to document the features observed in this disease. Optical coherence tomography angiography was particularly useful in showing the extension of the neovascular network and response to treatment.

Unilateral Acute Idiopathic Maculopathy Associated with Streptococcal Pharyngitis, A Case Report

Purpose: Unilateral Acute Idiopathic Maculopathy (UAIM) is a rare inflammatory macular condition affecting young adults with poorly understood etiology. This case report addresses this by suggesting potential etiology.Methods: A retrospective review of patient records was carried out to obtain data for case report.Results: A 29-year-old male developed sudden visual loss in the left eye 1 day following the development of a sore throat. Optical Coherence Tomography (OCT) and fundal exam demonstrated subretinal/intraretinal fluid and disruption of the outer retina in keeping with UAIM. Serological testing revealed a raised Anti-Streptolysin O Titer and anti-DNAse-B antibody.Conclusions: To date, UAIM has been known to be associated with a flu-like illness and a connection between coxsackievirus has been suggested but it has not been linked to streptococcal pharyngitis. We suggest a potential link between UAIM and streptococcal infection and that UAIM may be on the spectrum of post-streptococcal autoimmune disease.

Hand, Foot and Mouth Disease in Immunocompetent Adult with Severe Oral Manifestation

Hand-foot-mouth Disease (HFMD) is an acute, self-limited, and highly contagious disease caused by a virus and generally affects children under 10 years old. The etiology of this disease is enterovirus 71 or coxsackievirus A16 which usually causes symptomatic infection or mild disease. Immunocompetent adults are rarely affected. However, recently the incidence of HFMD in immunocompetent adults has increased. We report a 41-year-old woman with severe oral lesions and painful papulovesicular eruption on the palms of her hands and feet.

Is choriocapillaris the early target in acute maculopathy secondary to hand, foot, and mouth disease? A case report

PURPOSE

To report the case of a 33-year old man who disclosed the first case of bilateral ocular involvement of hand, foot, and mouth disease (HFMD) with a different stage of the disease in each eye.

METHODS

Retrospective case report.

RESULTS

The study included a patient who incurred in a bilateral HFMD maculopathy. During 6 months follow-up period persistent abnormalities in fundus examination and in OCT scans were reported.

CONCLUSION

We consider that our case shows that choriocapillaris is the primary target of HFMD maculopathy, for this reason we consider that ICGA is mandatory for early diagnosis and an effective treatment.

Acute unilateral maculopathy associated with adult onset of hand, foot and mouth disease: a case report

Background

To report the case of a 31-year-old patient with Hand, Foot and Mouth Disease (HFMD) and concurrent acute monocular maculopathy, and to describe multimodal imaging findings never before described including optical coherence tomography angiography (OCT-A).

Case presentation

Nine days after the onset of clinically highly probable but not laboratory-verified HFMD, a 31-year old male noticed a central scotoma, distorted lines and loss of visual acuity (Snellen visual acuity 20/400) in his right eye. Funduscopy revealed focal alterations in the retinal pigmented epithelium (RPE) and yellow retinal dots corresponding to focal dots of decreased fundus autofluorescence (FAF) surrounded by increased FAF. Spectral domain optical coherence tomography (SD-OCT) demonstrated irregularities in the ellipsoide zone, hyperreflective dots above the RPE and RPE thickening. Fundus fluorescein angiography (FAG) revealed central hypofluorescence in the macular area in the early phase, as well as increasing focal hyperfluorescence in the late phase corresponding with RPE defects observed in FAF. Indocyanine green angiography (ICGA) showed central hypofluorescence in the early and late phase, corresponding with areas of reduced flow in the choroidea and choriocapillaris as apparent in OCT-A. Visual acuity improved within 3 months without any systemic or local therapy. At his three-month follow-up, SD-OCT revealed subtle subretinal fluid that resolved spontaneously over time. No signs of choroidal neovascularization were observed. Twelve months following the onset of symptoms Snellen visual acuity was 400/400. Multimodal imaging revealed subtly changed, decreased FAF while the choroidal architecture recovered completely as demonstrated by OCT-A.

Conclusions

HFMD-associated maculopahty is an uncommon but important differential diagnosis of chorioretinitis with macular involvement. The prognosis can be good and the initially observed morphological pathologies such as impaired perfusion of the choroidal vessels can recover spontaneously over a period lasting 12 months. OCT-A can be employed as a non-invasive tool to detect the reduced perfusion of the choroidal vessels and for monitoring the disease course.

Central serous retinopathy and hand-foot-mouth disease: coincidence or causation?

Introduction

The clinical and pathological correlation between hand–foot–mouth disease (HFMD) and ocular complications has not yet been established. However, individual case reports indicate a trend that may be the emergence of a new burden of the previous self-limiting virus. This virus is particularly prevalent in childcare centers and poses an infectious disease risk for this workplace.

Objectives

The primary objective of this case report is to describe an unusual clinical record of a patient who developed central serous retinopathy while unwell with HFMD. Discussion of management strategies for this workplace, its staff, and visitors is also included.

Methods

This was an observational case report that was identified and reported retrospectively. For comparison, a search of the literature to identify similar ocular complications of HFMD was also undertaken. Results from this search, in addition to international data and prevention and management strategies are also provided.

Results

A total of 13 individual case reports with ocular associations, including this clinical record, were identified in the literature worldwide. The median age was 33 years, and three patients (23%) were female. No treatment or management guidelines for ocular complications of HFMD have been identified.

Conclusion

Severe and potentially life-threatening complications of a seemingly harmless childhood illness are represented sporadically in the literature. The requirement for research and evaluation into this emerging occupational hazard area is necessary for improved prevention, management, and treatment strategies to be developed.

Anti-vascular endothelial growth factor for unilateral acute idiopathic maculopathy

PURPOSE

To describe a case of unilateral acute idiopathic maculopathy (UAIM) response to intravitreal therapy with aflibercept (Eylea).

METHODS

Retrospective case report.

RESULTS

A 36-year-old woman with sudden visual impairment and central scotoma was found to have a UAIM in her left eye. Three weeks after continuous worsening of her visual acuity and central scotoma, the patient was treated with intravitreal injections of aflibercept. The visual acuity increased and the macula lesion regressed, causing macula scarring after 2 injections.

CONCLUSIONS

Intravitreal injections of aflibercept could be a therapy option in patients with UAIM without signs of spontaneous resolution of the clinical manifestations and visual improvement.

Unilateral hemorrhagic maculopathy: An uncommon manifestation of hand, foot, and mouth disease

Hand, foot, and mouth disease (HFD) is a common systemic infection occurring in childhood or immunocompromised adults caused by enteroviruses, the most common being coxsackievirus A16 and enterovirus 71. It is characterized by maculopapular eruptions over the hands and feet and ulcerative stomatitis. Ocular involvement is a rare complication and commonly manifests as inflammatory macular pathology. We report a case of HFD in an immunocompetent adult male with unilateral ocular involvement presenting as hemorrhagic maculopathy and its management with complete anatomical and functional recovery.

A literature review and case report of hand, foot and mouth disease in an immunocompetent adult

Background

To report an uncommon case of hand, foot and mouth disease, (HFMD) in an immunocompetent adult; a highly infectious disease, characterized by the appearance of vesicles on the mouth, hands and feet, associated with coxsackieviruses and enteroviruses; including a literature review.

Case report

A 23 year Caucasian male with no medical or surgical history, no allergies, was not taking any medication and smoked ten cigarettes a day, suffering from discomfort in the oral cavity; itching, burning and pain when swallowing associated with small erythematous lesions located on the hard palate, and small ulcers in tonsillar pillars and right buccal mucosa. Mild fever of 37.8 °C and general malaise. The patient reported he had had contact with a child diagnosed with HFMD. From his background and symptoms, the patient was diagnosed with HFMD. Following symptomatic treatment, the symptoms remitted in 7 days.

Methods

A literature review in MEDLINE (PubMed). The inclusion criteria were for studies on humans over the last 5 years, using the keywords HFMD.

Results

We found 925 articles, which were subsequently reduced to 52 documents after applying the inclusion criteria. Maculopapular lesions were found on hands and feet.

Conclusions

Dentists may have a key role diagnosing the disease. A surveillance system to predict future outbreaks, encourage early diagnosis, put appropriate public health measures in place and research vaccine development is vitally important in order to control the disease.