Infectious optic neuropathies: a clinical update

Infectious eye disease in the 21st century-an overview

Infectious diseases affecting the eye often cause unilateral or asymmetric visual loss in children and people of working age. This group of conditions includes viral, bacterial, fungal and parasitic diseases, both common and rare presentations which, in aggregate, may account for a significant portion of the global visual burden. Diagnosis is frequently challenging even in specialist centres, and many disease presentations are highly regional. In an age of globalisation, an understanding of the various modes of transmission and the geographic distribution of infections can be instructive to clinicians. The impact of eye infections on global disability is currently not sufficiently captured in global prevalence studies on visual impairment and blindness, which focus on bilateral disease in the over-50s. Moreover, in many cases it is hard to differentiate between infectious and immune-mediated diseases. Since infectious eye diseases can be preventable and frequently affect younger people, we argue that in future prevalence studies they should be considered as a separate category, including estimates of disability-adjusted life years (DALY) as a measure of overall disease burden. Numbers of ocular infections are uniquely affected by outbreaks as well as endemic transmission, and their control frequently relies on collaborative partnerships that go well beyond the remit of ophthalmology, encompassing domains as various as vaccination, antibiotic development, individual healthcare, vector control, mass drug administration, food supplementation, environmental and food hygiene, epidemiological mapping, and many more. Moreover, the anticipated impacts of global warming, conflict, food poverty, urbanisation and environmental degradation are likely to magnify their importance. While remote telemedicine can be a useful aide in the diagnosis of these conditions in resource-poor areas, enhanced global reporting networks and artificial intelligence systems may ultimately be required for disease surveillance and monitoring.

Programmed axon death: a promising target for treating retinal and optic nerve disorders

Programmed axon death is a druggable pathway of axon degeneration that has garnered considerable interest from pharmaceutical companies as a promising therapeutic target for various neurodegenerative disorders. In this review, we highlight mechanisms through which this pathway is activated in the retina and optic nerve, and discuss its potential significance for developing therapies for eye disorders and beyond. At the core of programmed axon death are two enzymes, NMNAT2 and SARM1, with pivotal roles in NAD metabolism. Extensive preclinical data in disease models consistently demonstrate remarkable, and in some instances, complete and enduring neuroprotection when this mechanism is targeted. Findings from animal studies are now being substantiated by genetic human data, propelling the field rapidly toward clinical translation. As we approach the clinical phase, the selection of suitable disorders for initial clinical trials targeting programmed axon death becomes crucial for their success. We delve into the multifaceted roles of programmed axon death and NAD metabolism in retinal and optic nerve disorders. We discuss the role of SARM1 beyond axon degeneration, including its potential involvement in neuronal soma death and photoreceptor degeneration. We also discuss genetic human data and environmental triggers of programmed axon death. Lastly, we touch upon potential therapeutic approaches targeting NMNATs and SARM1, as well as the nicotinamide trials for glaucoma. The extensive literature linking programmed axon death to eye disorders, along with the eye's suitability for drug delivery and visual assessments, makes retinal and optic nerve disorders strong contenders for early clinical trials targeting programmed axon death.

How far should I manage acute optic neuritis as an ophthalmologist? A United Kingdom perspective

Optic neuritis (ON) is an inflammation of or around the optic nerve, frequently caused by infectious or immune-mediated inflammatory disorders. In the UK, its strongest association is with Multiple Sclerosis (MS), though the combined prevalence of other associated infectious and immune-mediated inflammatory diseases (I-IMID) is similar to that of MS-ON. Prompt identification and understanding of ON's underlying cause informs tailored management and prognosis. Several IMIDs linked to ON, such as aquaporin-4 antibody-associated optic neuritis (AQP4-ON), myelin oligodendrocyte glycoprotein antibody-associated optic neuritis (MOG-ON), and neuro-sarcoidosis, show remarkable response to corticosteroid treatment. Therefore, urgent investigation and treatment are crucial in cases 'atypical' for MS-ON. Following the 1992 Optic Neuritis Treatment Trial, clinical practice has evolved, with short-course high-dose corticosteroids considered safe and effective for most people. Timely recognition of patients who could benefit is critical to avoid irreversible vision loss. This review provides a practical guide and a summary of evidence on the investigation and management of acute optic neuritis. It reflects the knowledge and limitations of current evidence, framed through the neuro-ophthalmic perspective of clinical practice at multiple UK academic centres.

Infectious optic neuropathy (ION), how to recognise it and manage it

Optic neuropathy can be of infectious or non-infectious/idiopathic aetiology. Many infectious organisms can cause optic neuropathy that can be of varied presentation including papillitis, retrobulbar optic neuritis, neuroretinitis, and optic perineuritis. Detailed history, ocular, systemic/neurologic examination along with appropriate laboratory evaluation can help clinicians to identify the infectious agent causing optic neuropathy. In spite of recent advanced techniques in serological testing and molecular diagnostics like polymerase chain reaction (PCR), the identification of these pathogens is still a diagnostic challenge. It is ideal to have an infectious disease (ID) consultant in the management team, as most of these infections are multisystem involving diseases. Most infectious agents can be effectively treated with specific antibiotics, with or without corticosteroid therapy, but visual recovery is highly variable and depends entirely on early diagnosis of the causative agent. This review article will provide an overview of common pathogens involved in ION and will describe their management paradigms.

MOG antibody-associated optic neuritis

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is a demyelinating disorder, distinct from multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). MOGAD most frequently presents with optic neuritis (MOG-ON), often with characteristic clinical and radiological features. Bilateral involvement, disc swelling clinically and radiologically, and longitudinally extensive optic nerve hyperintensity with associated optic perineuritis on MRI are key characteristics that can help distinguish MOG-ON from optic neuritis due to other aetiologies. The detection of serum MOG immunoglobulin G utilising a live cell-based assay in a patient with a compatible clinical phenotype is highly specific for the diagnosis of MOGAD. This review will highlight the key clinical and radiological features which expedite diagnosis, as well as ancillary investigations such as visual fields, visual evoked potentials and cerebrospinal fluid analysis, which may be less discriminatory. Optical coherence tomography can identify optic nerve swelling acutely, and atrophy chronically, and may transpire to have utility as a diagnostic and prognostic biomarker. MOG-ON appears to be largely responsive to corticosteroids, which are often the mainstay of acute management. However, relapses are common in patients in whom follow-up is prolonged, often in the context of early or rapid corticosteroid tapering. Establishing optimal acute therapy, the role of maintenance steroid-sparing immunotherapy for long-term relapse prevention, and identifying predictors of relapsing disease remain key research priorities in MOG-ON.

Systematic review exploring the clinical features of optic neuritis after SARS-CoV infection and vaccination

BACKGROUND

This study aims to characterise the symptoms and clinical features of optic neuritis (ON) following SARS-CoV-2 infection and vaccination.

METHOD

A literature search was conducted in four databases (PubMed, Medline, Embase and Google Scholar) to identify relevant case reports and case series. The records were screened and articles adhering to the inclusion criteria were critically appraised.

RESULTS

Sixty-eight studies were found to be eligible for inclusion, including 34 reporting ON following SARS-CoV-2 infection and an equal number reporting cases postvaccination. In total 93 patients and 125 eyes were included. The infection cohort included 42 patients and 56 eyes, 51.2% were female and 33.3% experienced bilateral ON. The mean visual acuity was 1.64 log of minimum angle of resolution (LogMAR), while pain was present in 77.8%. Oligoclonal bands were present in 3 patients, myelin oligodendrocyte glycoprotein (MOG) antibodies in 18 patients and AQP-4 antibodies in 4 patients. The vaccination cohort included 51 patients and 69 eyes. 60.8% were female and 35.3% had a bilateral ON. The mean visual acuity was 0.93 LogMAR. Oligoclonal bands were present in 46.7%, MOG antibodies in nine patients and AQP-4 antibodies in three patients.

CONCLUSION

Patients with ON post-SARS-CoV infection were more likely to experience severe visual impairment than in cases following vaccination. Further research is required to outline the clinical features of ON after COVID-19 infection and vaccination, and establish causality.

Systemic and Ophthalmic Manifestations of Chikungunya Fever

PURPOSE

Chikungunya is a re-emerging viral infection across the globe. The purpose of this article is to review the systemic and ophthalmic manifestations associated with chikungunya fever.

METHOD

A review of literature was conducted using online databases.

RESULTS

In this report, we have reviewed the presently available literature on uveitis caused by chikungunya and highlighted the current knowledge of its clinical manifestations, imaging features, laboratory diagnostics, and the available therapeutic modalities from the systemic and ophthalmic standpoint.

CONCLUSIONS

Ocular involvement in chikungunya infection may occur at the time of systemic manifestations or it may occur as a delayed presentation many weeks after the fever. Treatment relies on a supportive therapy for systemic illness. Treatment of ocular manifestation depends on the type of manifestations and usually includes a combination of topical and oral steroids.

A Case of Neuroretinitis Following COVID-19 Vaccination

PURPOSE

To present a case of neuroretinitis following an mRNA COVID-19 vaccination.

CASE REPORT

A 78-year-old healthy woman was presented with blurry vision in her left eye 1 day after receiving the third dose of the Pfizer-BioNTech COVID-19 vaccine. The ocular examination revealed an optic disc swelling and retinal thickening of the macula with subretinal fluid in the left eye. The fluorescein angiography revealed hyperfluorescence of the left optic disc. The neuroretinitis resolved gradually after taking azithromycin and prednisolone orally.

CONCLUSIONS

This is the first report of unilateral neuroretinitis following COVID-19 vaccination, implying a potential association between the mRNA vaccine and neuroretinitis.

Case Report: Severe Optic Neuritis after Multiple Episodes of Malaria in a Traveler to Africa

Although local transmission of malaria has been eliminated, the disease is frequently imported to China by Chinese travelers returning from Africa. Optic neuritis (ON) is occasionally reported in malarial cases and usually shows good visual recovery and prognosis. Herein, we report severe visual loss with poor recovery due to bilateral ON in a malarial patient who traveled from Nigeria. While he was still in Nigeria, his visual acuity dropped to no light perception in both eyes after the third episode of malaria, which was confirmed by a positive blood smear for malarial parasites. His general condition gradually improved after a 6-day course of artesunate therapy. However, visual acuity in both eyes remained unchanged after artesunate therapy alone, with gradual improvement subsequently shown after pulse steroid therapy. Our case indicates that early antimalarial drugs combined with pulse steroid therapy may be of great importance for good visual recovery in ON cases after malarial infection.

Extracellular vesicles as a new horizon in the diagnosis and treatment of inflammatory eye diseases: A narrative review of the literature

Extracellular vesicles include exosomes, microvesicles, and apoptotic bodies. Their cargos contain a diverse variety of lipids, proteins, and nucleic acids that are involved in both normal physiology and pathology of the ocular system. Thus, studying extracellular vesicles may lead to a more comprehensive understanding of the pathogenesis, diagnosis, and even potential treatments for various diseases. The roles of extracellular vesicles in inflammatory eye disorders have been widely investigated in recent years. The term “inflammatory eye diseases” refers to a variety of eye conditions such as inflammation-related diseases, degenerative conditions with remarkable inflammatory components, neuropathy, and tumors. This study presents an overview of extracellular vesicles’ and exosomes’ pathogenic, diagnostic, and therapeutic values in inflammatory eye diseases, as well as existing and potential challenges.

Dengue fever ophthalmic manifestations: A review and update

Dengue fever, the most common arbovirus disease, affects an estimated 390 million people annually. Dengue virus (DENV) is an RNA virus of the Flaviviridae family with four different serotypes. Dengue haemorrhagic fever is the deadliest form of dengue infection and is characterised by thrombocytopaenia, hypotension, and the possibility of multi-system organ failure. The mechanism hypothesised for DENV viral replication is intrinsic antibody-dependent enhancement, which refers to Fcγ receptor-mediated viral amplification. This hypothesis suggests that the internalisation of DENV through the Fcγ receptor inhibits antiviral genes by suppressing type-1 interferon-mediated antiviral responses. DENV NS1 antibodies can promote the release of various inflammatory mediators in the nuclear transcription factor pathway (NF-κB-dependent), including monocyte chemoattractant protein (MCP)-1, interleukin (IL)-6, and IL-8. As a result, MCP-1 increases ICAM-1 expression and facilitates leukocyte transmigration. In addition, anti-DENV NS1 antibodies induce endothelial cell apoptosis via a nitric oxide-regulated pathway. A chain reaction involving pre-existing DENV heterotypic antibodies and innate immune cells causes dysfunction in complement system activity and contributes to the action of autoantibodies and anti-endothelial cells, resulting in endothelial cell dysfunction, blood-retinal barrier breakdown, haemorrhage, and plasma leakage. A spectrum of ocular diseases associated with DENV infection, ranging from haemorrhagic to inflammatory manifestations, has been reported in the literature. Although rare, ophthalmic manifestations can occur in both the anterior and posterior segments and are usually associated with thrombocytopenia. The most common ocular complication is haemorrhage. However, ophthalmic complications, such as anterior uveitis and vasculitis, suggest an immune-mediated pathogenesis.

Clinical spectrum of first episode of optic neuritis in a tertiary care hospital in Southern India - A retrospective analysis

PURPOSE

The purpose of this study was to determine the demographic and clinical patterns of optic neuritis (ON) in patients presenting to a tertiary health-care institute and to study the incidence of multiple sclerosis (MS), magnetic resonance imaging features in varied ON, treatment outcome, and prognosis.

METHODS

A retrospective analysis of patients with first episode of ON presenting to a tertiary care center during the period from March 2013 to March 2021 was done. Details of ocular examination were retrieved from medical records and statistically analyzed.

RESULTS

Three hundred and fifty-four participants with ON were included in this study. The mean age was 40.25 ± 12.2 years. The male: female ratio was 1:1.35. 48.1% had visual acuity of <3/60. Based on clinical presentation, papillitis was seen in 31.5% of subjects, neuroretinitis in 24.1%, and retrobulbar neuritis in 44.4%. Based on etiology, 79.6% were idiopathic, 1.8% presented with infectious ON, and 9.26% were associated with demyelinating disease (MS).

CONCLUSION

Females were predominantly affected. Idiopathic ON formed the major subset etiologically. Sixty-six percent had visual recovery of 6/18 or better following corticosteroid therapy. 9.2% revealed multiple intracranial lesions on neuroimaging, suggesting high association with MS. Therefore, early diagnosis, vigilant monitoring of steroid therapy, and regular follow-up screening for MS remain the mainstay of management in ON.

Peripapillary Nerve Fiber Layer Thickness and Optic Nerve Head Parameters in Patients Recovered from COVID-19: A Longitudinal Study

Purpose

To quantify the longitudinal changes of the optic nerve head (ONH) parameters and peripapillary retinal nerve fiber layer (pRNFL) thickness in patients recovered from coronavirus disease 2019 (COVID-19) using spectral-domain optical coherence tomography (OCT) analysis.

Materials and Methods

In an observational longitudinal study, in patients recovered from COVID-19, ONH OCT images were recorded at least two weeks after recovery from the systemic disease as the baseline and after one and three-month follow-up. Ganglion cell complex (GCC) analysis, ONH parameters, and pRNFL thickness changes were measured.

Results

A total of 36 eyes from 18 recovered COVID-19 patients including eleven (61.2%) females were studied. The average age was 35.5 ± 7.5 years. The pRNFL thickness in the nasal lower sector significantly decreased from 77 ± 18 μm in the first post-COVID-19 month to 74 ± 10 μm in the third month (P=0.8). The average, superior, and inferior pRNFL thickness remained unchanged. The average cup volume significantly decreased from 0.27 ± 0.15 mm³ at baseline to 0.19 ± 0.15 mm³ in the third post-COVID-19 visit (P=0.028). In terms of ONH morphologies including rim, disc and cup to disc area, and the vertical and horizontal ratio, the changes were not significant over the 3-month study period. Focal loss volume and global loss volume values were not changed significantly.

Conclusion

Localized defect in the nasal lower sector of pRNFL is observed in 3-month post-recovery from COVID-19. Larger studies with longer follow-ups are required to reveal the exact changes in ONH parameters.

A rare presentation of Klebsiella pneumoniae endogenous panophthalmitis with optic neuritis and orbital cellulitis from a urinary tract infection

This case illustrates the rare presentation of endogenous Klebsiella pneumoniae endophthalmitis with concomitant orbital cellulitis from an acute pyelonephritis. A 59-year-old Caucasian female with type 2 diabetes mellitus was transferred from a regional hospital with decreased visual acuity, periorbital edema, photophobia, proptosis and pain of the right eye, as well as suprapubic discomfort. Initial ocular examination and B-scan ultrasonography were consistent with endophthalmitis and orbital cellulitis which lead to a vitreous tap and intravitreal antibiotics injection and systemic antibiotherapy. Vitreous and blood cultures confirmed Klebsiella pneumoniae as the causative organism. An orbital MRI showed a panophthalmitis with optic neuritis and further imaging confirmed a concomitant pyelonephritis secondary to a septic nephrolithiasis. The patient was given treatment with high-does intravenous antibiotics, oral and topical corticotherapy, and an early core pars plana vitrectomy (PPV), performed 5 days after presentation with repeat injections of antibiotics and dexamethasone. Unfortunately, two weeks following PPV, despite an initial stable postoperative course, the patient deteriorated and presented with purulent discharge from one of the vitrectomy port incision site. An emergency evisceration was performed in order to control the infection, revealing a large subretinal abscess and necrosed sclerotic tissue around the prior vitrectomy incision sites. Conclusion: This is the first case report of Klebsiella pneumoniae endophthalmitis or panophthalmitis presenting with orbital cellulitis and optic neuritis from an urinary tract infection. Prognosis is poor despite treatment including early vitrectomy.

A case series of post COVID-19 mucormycosis-a neurological prospective

Background

Direct neurological manifestations of coronavirus disease whether peripheral or central are reported worldwide. Yet, along the 3rd wave of the pandemic especially in India, an associated angioinvasive opportunistic infection with mucormycosis in COVID-19 cases is emerging.

Case presentation

The current case series which represents 4 patients with mucormycosis post COVID-19 is one of a few if not the first case series that discusses post COVID-19 mucormycosis from a neurological prospective in a tertiary hospital in Egypt.

All cases but one presented with total ophthalmoplegia, and only one was diagnosed as a cavernous sinus thrombosis; meanwhile, orbital cellulitis and orbital apex syndrome were responsible of ophthalmoplegia in two cases.

Mortality reached 25%, and the case that died suffered cutaneous as well as rhino-cerebral type with a delayed presentation to hospital.

Conclusion

A rare but fatal fungal infection is ought to be nowadays kept in mind in COVID-19 active cases as well as in recovered COVID-19 patients, especially those who have comorbid medical conditions as uncontrolled diabetes and who were treated with large doses of corticosteroids.

Spirochetal uveitis: Spectrum of clinical manifestations, diagnostic and therapeutic approach, final outcome and epidemiological data

PURPOSE

Analysis of cases with spirochetal uveitis related to spirochetes in a tertiary referral academic center.

METHODS

Retrospective study of patients diagnosed with uveitis attributed to Treponema pallidum, Leptospira spp. and Borrelia burgdorferi from June 1991 until December 2019.

RESULTS

A total of 57 cases of spirochetal uveitis (22 patients with T. pallidum, 26 with Leptospira spp., and 9 with B. burgdorferi) that consisted 1% of the overall number of uveitics were recorded. All these cases presented with a wide spectrum of clinical presentations (anterior uveitis, posterior uveitis, panuveitis, vasculitis, papillitis, and in some rare cases concomitant posterior scleritis). The treatment included mainly penicillin or doxycycline, while corticosteroids were administered systematically in some cases with Borrelia or Leptospira infection. The final visual outcome was favorable (> 6/10 in Snellen visual acuity) in approximately 76% of our patients.

CONCLUSION

Despite being rare, spirochetal uveitis can be detrimental for the vision and must always be included in the differential diagnosis.

Bilateral optic neuritis with spine demyelination associated with influenza A H1N1 infection

Purpose

To report a rare case of optic neuritis with spine demyelination following H1N1 virus infection.

Observation

A 66-year-old female presented with decreased vision in both eyes (left > right) following a recent episode of fever and flu. She was diagnosed as H1N1 infection confirmed by viral antigen analysis of throat swab. On examination, she had a profound vision drop in the left eye with optic disc edema. MRI brain and orbit revealed bilateral optic nerve and frontal dural thickening with a ring-enhancing lesion in the right frontal lobe. MRI spine showed long cord signals at T1-T7 suggestive of demyelination. The patient had a complete recovery of vision and visual fields after intravenous and oral steroids.

Conclusion/Importance

Influenza A virus can manifest with a wide range of symptoms including flu-like illness to neurological complications. This case highlights optic neuritis as a presenting feature of H1N1 infection.

Whole Mitochondrial Genome Analysis in Serbian Cases of Leber's Hereditary Optic Neuropathy

Leber’s hereditary optic neuropathy (LHON) is a maternally inherited disorder that affects central vision in young adults and is typically associated with mitochondrial DNA (mtDNA) mutations. This study is based on a mutational screening of entire mtDNA in eight Serbian probands clinically and genetically diagnosed with LHON and four of their family members, who are asymptomatic mutation carriers. All obtained sequence variants were compared to human mtDNA databases, and their potential pathogenic characteristics were assessed by bioinformatics tools. Mitochondrial haplogroup analysis was performed by MITOMASTER. Our study revealed two well-known primary LHON mutations, m.11778G>A and m.3460G>A, and one rare LHON mutation, m.8836A>G. Various secondary mutations were detected in association with the primary mutations. MITOMASTER analysis showed that the two well-known primary mutations belong to the R haplogroup, while the rare LHON m.8836A>G was detected within the N1b haplogroup. Our results support the need for further studies of genetic background and its role in the penetrance and severity of LHON.

Bilateral Optic Neuritis: A Rare Complication of Mumps

Mumps is a contagious viral illness that classically presents with fever, parotid gland swelling, headache, and vomiting in unimmunized children. The complications of mumps most commonly include orchitis, pancreatitis, encephalitis, and meningitis. Optic neuritis, which refers to the inflammation of the optic nerve, in rare cases, can present after mumps meningoencephalitis and causes pain in the eye, and a decrease in visual acuity. We report and discuss a case of bilateral optic neuritis following mumps meningoencephalitis in a child. The patient was managed with short-term steroid therapy.

Optic Neuritis

PURPOSE OF REVIEW

This article discusses the clinical presentation, evaluation, and management of the patient with optic neuritis. Initial emphasis is placed on clinical history, examination, diagnostic testing, and medical decision making, while subsequent focus is placed on examining specific inflammatory optic neuropathies. Clinical clues, examination findings, neuroimaging, and laboratory testing that differentiate autoimmune, granulomatous, demyelinating, infectious, and paraneoplastic causes of optic neuritis are assessed, and current treatments are evaluated.

RECENT FINDINGS

Advances in technology and immunology have enhanced our understanding of the pathologies driving inflammatory optic nerve injury. Clinicians are now able to interrogate optic nerve structure and function during inflammatory injury, rapidly identify disease-relevant autoimmune targets, and deliver timely therapeutics to improve visual outcomes.

SUMMARY

Optic neuritis is a common clinical manifestation of central nervous system inflammation. Depending on the etiology, visual prognosis and the risk for recurrent injury may vary. Rapid and accurate diagnosis of optic neuritis may be critical for limiting vision loss, future neurologic disability, and organ damage. This article will aid neurologists in formulating a systematic approach to patients with optic neuritis.

Ocular Manifestations of Mosquito-Transmitted Diseases

Of the 3,548 known mosquito species, about 100 transmit human diseases. Mosquitoes are distributed globally throughout tropical and temperate regions where standing water sources are available for egg laying and the maturation of larva. Female mosquitoes require blood meals for egg production. This is the main pathway for disease transmission. Mosquitoes carry several pathogenic organisms responsible for significant ocular pathology and vision loss including West Nile, Rift Valley, chikungunya, dengue viruses, various encephalitis viruses, malarial parasites, Francisella tularensis, microfilarial parasites, including Dirofilaria, Wuchereria, and Brugia spp., and human botfly larvae. Health care providers may not be familiar with many of these mosquito-transmitted diseases or their associated ocular findings delaying diagnosis, treatment, and recovery of visual function. This article aims to provide an overview of the ocular manifestations associated with mosquito-transmitted diseases.

Case Report: Ocular toxoplasmosis in a WHIM syndrome immunodeficiency patient

A patient with WHIM syndrome immunodeficiency presented with sudden painless right eye blindness associated with advanced retinal and optic nerve damage. Toxoplasma gondii was detected by PCR in vitreous fluid but not serum.  The patient was treated with pyrimethamine/sulfadiazine for 6 weeks due to evidence of active ocular inflammation and then received prophylaxis with trimethoprim-sulfamethoxazole due to his immunosuppression.  Vision did not return; however, the infection did not spread to involve other sites.  Toxoplasmosis is rare in primary immunodeficiency disorders and is the first protozoan infection reported in WHIM syndrome.

Case Report: Ocular toxoplasmosis in a WHIM syndrome immunodeficiency patient

A patient with WHIM syndrome immunodeficiency presented with sudden painless right eye blindness associated with advanced retinal and optic nerve damage. Toxoplasma gondii was detected by PCR in vitreous fluid but not serum.  The patient was treated with trimethoprim-sulfamethoxazole.  Vision did not return; however, the infection did not spread to involve other sites.  Toxoplasmosis is rare in primary immunodeficiency disorders and is the first protozoan infection reported in WHIM syndrome.

Central Nervous System Involvement in Common Variable Immunodeficiency: A Case of Acute Unilateral Optic Neuritis in a 26-Year-Old Italian Patient

Common Variable Immunodeficiency (CVID) is a group of heterogeneous primary immunodeficiencies sharing defective B lymphocytes maturation and dysregulated immune response and resulting in impaired immunoglobulin production. Clinical picture encompasses increased susceptibility to infections, hematologic malignancies, inflammatory, and autoimmune diseases. Neurological manifestations are uncommon and optic neuritis has been previously reported only in one case with bilateral involvement. We hereby report a case of a 26-year-old man affected by CVID undergoing regular immunoglobulin supplementation, who presented with acute unilateral demyelinating optic neuritis and lymphocytic pleocytosis in the cerebrospinal fluid. A variety of infectious, inflammatory, and neoplastic conditions were excluded and a diagnosis of clinically isolated optic neuritis was made. The patient was treated with a short course of intravenous steroids with complete recovery. Overall, this case expands our current knowledge about clinical spectrum of complications in CVID and highlights the need for further research about this complex disease.