Skin biopsies in the evaluation of atypical optic neuropathies

Bilateral Syphilitic Optic Neuropathy with Secondary Autoimmune Optic Neuropathy and Poor Visual Outcome

We describe the case of a 65-year-old man who suffered progressive visual loss despite appropriate treatment of ocular syphilis. Our patient initially presented with a unilateral 6th nerve palsy and associated double vision, which self-resolved over 6 months. His ophthalmic examination was otherwise normal. 12 months after the initial complaint, he represented with dyschromatopsia, reduced visual acuity, tonic pupils, and optic nerve atrophy. He tested positive for syphilis and was admitted for treatment of neurosyphilis with high-dose benzylpenicillin. Despite treatment, at a 4-month review his visual acuity remained poor and progression of optic nerve atrophy was noted alongside the development of bilateral central scotomas. Further testing was congruent with a diagnosis of autoimmune optic retinopathy. We propose this to be secondary to his syphilitic infection. Syphilis is known as the "great mimicker," and despite being quite treatable, this case highlights ongoing complexity in the diagnosis and management of syphilis, unfortunately with a poor visual outcome.

Inflammatory optic neuropathies

PURPOSE OF REVIEW

The aim of this review is to highlight the clinical presentation of a variety of inflammatory optic neuropathies through a case-based format. While emphasis will be placed on optic neuritis, which represents the most common acquired inflammatory optic nerve injury, the cardinal clinical features of other demyelinating forms of optic neuropathy and potential mimics for typical optic neuritis will be discussed.

RECENT FINDINGS

Novel developments in the diagnostic evaluation, clinical associations, and treatment options for several inflammatory optic neuropathies will be described. Key points will emphasize clinical pearls and potential pitfalls that may thwart early diagnosis of underlying demyelinating, infectious, and inflammatory diseases presenting with optic nerve involvement.

SUMMARY

This review will aid the clinician in identifying potential red flags that should prompt consideration for causes of inflammatory optic nerve injury linked to neurologic and systemic disorders, and help guide safe and effective management for these conditions.

Bilateral vision loss responsive to corticosteroids

A 48-year-old woman presented with painless bilateral vision loss that began in the left eye and responded to steroids, followed by vision loss in the right eye one day after completing her steroid taper. Diagnosis was complicated by a positive screening test for Leber hereditary optic neuropathy and a negative workup for demyelinating disease. Steroid-dependent optic neuropathies such as autoimmune optic neuropathy and chronic relapsing inflammatory optic neuropathy were considered in the differential. Seven months after initial presentation, the patient developed a new periventricular white matter lesion, lesions on her cervical and thoracic spinal cord, bilateral leg weakness, and sensory loss consistent with multiple sclerosis.

Demyelination in rheumatic diseases

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) characterised by multifocal areas of demyelination in the white matter of the brain and spinal cord. Autoantibodies, for example antinuclear antibodies, can also be present. MS and other demyelinating processes, such as transverse myelitis and optic neuritis (which may be clinically isolated cases or be part of the clinical spectrum of MS), are sometimes difficult to differentiate from CNS involvement in systemic autoimmune diseases like systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), Sjoegren's syndrome (SS), and Adamantiades-Behcet disease (BD). An acute isolated neurological syndrome presents the biggest diagnostic problem, since it is common in MS, but can also be the only feature or first manifestation in SLE, APS, SS, and BD. Indeed, the clinical presentation and lesions evidenced by magnetic resonance imaging may be similar.

Autoimmune optic neuropathy with anticardiolipin antibody mimicking multiple sclerosis in a child

PURPOSE

To demonstrate that autoimmune optic neuropathy (AON) may occur in the pediatric population.

DESIGN

Interventional case report.

METHODS

A 4-year-old developed four episodes of bilateral optic neuritis with mild concurrent weakness, ataxia, or dizziness; one episode of unilateral optic neuritis; and one episode of weakness over a period of 4 years.

RESULTS

Autoimmune optic neuropathy was diagnosed because of the presence of anticardiolipin antibody and an abnormal skin biopsy with thrombin and immunoreactant deposition. She was treated with corticosteroids, aspirin, and gammaglobulin. This diminished the frequency and intensity of her attacks.

CONCLUSION

This case represents the diagnosis and treatment of AON in a child.