Encephalitis followed by optic neuritis: a case report and review of literature

To do or not to do: Large-dose steroid treatment for severe vision loss secondary to compressive inflammatory optic neuropathy in the setting of invasive fungal sinusitis

Purpose

Invasive fungal sinusitis (IFS) is associated with high rates of morbidity and mortality and often presents with orbital apex syndrome. Prompt diagnosis and management are crucial to prevent irreversible visual loss. We report a case of an immunosuppressed patient with rapidly progressive severe visual loss associated with frontal lobe cerebritis and leptomeningitis related to IFS, causing an adjacent compressive inflammatory optic neuropathy, which was treated successfully by large-dose corticosteroids.

Observations

A 29-year-old woman with acute myeloid leukemia status post chemotherapy presented with right-sided headaches and periorbital swelling. Her examination was significant for subjective red desaturation and trace right eyelid edema and ptosis. The remainder of her initial ocular examination was normal. Her labs demonstrated neutropenia and thrombocytopenia. Imaging of the brain and orbits was concerning for extensive sinus disease with intracranial extension. An urgent multi-sinus and optic nerve decompression was performed given concern for compressive optic neuropathy, and the biopsy was consistent with invasive fungal infection. Despite aggressive antifungal treatment, vision in her right eye decreased rapidly to counting fingers. No optic nerve abnormalities were observed on serial MRIs, but adjacent inferior frontal lobe enhancement was present. After a vigorous debate in a multidisciplinary meeting, her severe vision loss was attributed to cerebritis causing an adjacent compressive inflammatory optic neuropathy, and large-dose intravenous (IV) steroid treatment was initiated while maintaining systemic antifungal therapy. Remarkably, she had a full recovery of her vision.

Conclusions and importance

Severe vision loss in IFS can occur due to compressive inflammatory optic neuropathy without direct fungal invasion as a contributing factor. Timely and effective intervention is crucial in preventing vision loss. Large-dose steroid therapy may be a potential treatment option for immunocompromised patients with invasive fungal sinusitis and intracranial invasion, provided strict fungal infection control measures are in place.

A Case of Terson-Like Syndrome in a Patient with Viral Meningoencephalitis

The proposed mechanism of Terson's syndrome is increased intracranial pressure that leads to dilation of the retrobulbar optic nerve and compression of the central retinal vein. Terson's syndrome has been associated with many conditions that increase intracranial pressure such as venous sinus thrombosis, Moyamoya disease, leukemia, direct head trauma, and intraocular hemorrhage related to shaken baby syndrome. We present a novel case of a patient with recent viral prodrome found to have papilledema and multilayered retinal hemorrhages consistent with Terson syndrome. Computed tomography and magnetic resonance venography of the brain did not reveal any subdural, subarachnoid, or intracranial hemorrhages. However, cerebrospinal fluid analyses were significant for increased opening pressure and elevated protein levels, which were suggestive of viral meningoencephalitis. We describe this case as a Terson-like syndrome because the etiology of intraocular hemorrhage is increased intracranial pressure. However, this case does not fit the traditional presentation of Terson's syndrome as the intracranial pressure is secondary to meningeal inflammation instead of subdural, subarachnoid, or intracranial hemorrhage. We strongly feel that it is important for physicians to be aware of the link between viral meningoencephalitis and retinal conditions such as Terson-like syndrome because it can facilitate rapid diagnosis and treatment.

Herpes Simplex Virus 2 Meningoencephalitis-Associated Bilateral Optic Neuritis and Radiculitis

The most common ocular complication of herpes simplex virus (HSV) is acute retinal necrosis. We present a rare case of a patient with HSV-2 meningoencephalitis that developed severe vision-threatening optic neuritis. The patient was treated with steroids and IVIG, which allowed a rapid improvement in her vision.