ACUTE EXUDATIVE POLYMORPHOUS VITELLIFORM MACULOPATHY AS THE INITIAL PRESENTATION OF HUMAN IMMUNODEFICIENCY VIRUS INFECTION

PURPOSE

To describe the occurrence of acute exudative polymorphous vitelliform maculopathy as the initial presentation in a HIV-positive patient.

METHODS

Observational case report of one patient and literature review.

RESULTS

An active 21-year-old white woman presented to the emergency department with anterior segment complaints. Her best-corrected visual acuity was 20/20 in both eyes. Fundus examination revealed numerous, polymorphous, bleb-like lesions at the posterior pole, corresponding, on structural imaging (optical coherence tomography) to subretinal detachments. The bleb-like lesions on infrared imaging were slightly autofluorescent on fundus autofluorescence. Swept-source optical coherence tomography angiography showed signal attenuation because of the presence of subretinal fluid in the choriocapillaris segmentation. Multimodal imaging findings were suggestive for acute exudative polymorphous vitelliform maculopathy. Hence, a systemic blood workup was performed. The workup returned positive for HIV, and an antiviral therapy was introduced.

CONCLUSION

The fortuitous diagnosis of HIV having as the initial presentation acute exudative polymorphous vitelliform maculopathy in an asymptomatic patient highlights the value of a thorough clinical examination and multimodal imaging in correctly diagnosing this rare disorder and its cause. This case report could prove helpful to clinicians faced with this rare scenario.

Idiopathic acute exudative polymorphous vitelliform maculopathy: the importance of multimodal imaging, systemic workup and genetic testing

The authors describe a case of acute exudative polymorphous vitelliform maculopathy (AEPVM) in an otherwise healthy man in his 60s complaining of subacute bilateral blurred vision. At examination, best-corrected visual acuity was 20/32 in the right eye and 20/40 in the left eye. Bilateral central large serous detachments with inferior meniscus-like deposition of a vitelliform-like material were observed at funduscopy and confirmed by spectral-domain optical coherence tomography. Small vitelliform-like lesions along the temporal superior vascular arcades were also seen. The lesions with vitelliform appearance appeared hyperautofluorescent on fundus autofluorescence. A complete systemic workup and genetic testing were performed and the diagnosis of idiopathic AEPVM was established. Six months later, a complete resolution of the lesions was observed.

Acute bilateral serous retinal detachments with spontaneous resolution in a 6-year-old boy

A healthy 6-year-old boy presented with acute bilateral vision loss, multiple serous retinal detachments between the vascular arcades and a thickened choroid. Spontaneous resolution occurred over several weeks. We hypothesize that the clinical constellation in our patient is suggestive of acute exudative polymorphous vitelliform maculopathy (AEPVM) or might be an atypical presentation of Vogt-Koyanagi-Harada (VKH) disease. We propose that it was caused by an autoimmune-mediated activation of inflammatory cells at the level of the choroid, induced by an unknown trigger.

A case of acute exudative polymorphous vitelliform maculopathy: follow-up and wide-field spectral-domain optical coherence tomography

PURPOSE

To present a case of an HIV-positive patient with acute exudative polymorphous vitelliform maculopathy (AEPVM) and evaluate the presence of specific spectral-domain optical coherence tomography (SD-OCT) findings.

METHODS

Case report.

RESULTS

We reviewed the AEPVM cases reported in the literature and compared those to our patient to determine if there is a correspondence between the etiology that leads to the onset of AEPVM and clinical and SD-OCT findings.

CONCLUSIONS

Acute exudative polymorphous vitelliform maculopathy is a disease that involves the outer retinal layers with lipofuscin deposits and serous detachment of the neuroepithelium with or without intraretinal cysts. Not much is known about the etiology and pathogenesis, and not many cases have been described. A review of the few clinical cases reported in the literature does not show a specific correspondence between etiology and SD-OCT findings.

Nonantibestrophin Anti-RPE Antibodies in Paraneoplastic Exudative Polymorphous Vitelliform Maculopathy

PURPOSE

A previous report demonstrated antibodies to bestrophin in paraneoplastic exudative polymorphous vitelliform maculopathy (PEPVM). Other cases demonstrated antibodies to different proteins in the retinal pigment epithelium (RPE). In this report, serum was analyzed to determine whether a patient with PEPVM and a reduced Arden ratio had developed autoantibodies to human Bestrophin-1 (Best1).

METHODS

Human embryonic kidney 293 cells (HEK293) were transfected with Best1 and stained with an antibody specific to Best1 (E6-6), or patient serum. Staining patterns were compared with those of untransfected cells stained with E6-6, patient serum, control serum, or secondary antibody alone. Western blots were performed using lysed RPE and stained with E6-6, patient serum, control serum, or secondary antibody alone.

RESULTS

Immunofluorescence staining of HEK-293 cells or HEK-293 cells expressing Best1 did not differ between patient and control sera or show a staining pattern consistent with recognition of Best1. Immunoblotting of human RPE lysate with patient serum did not identify Best1 (68 kDa) but did recognize a band at approximately 48 kDa that was absent in blots using control serum.

CONCLUSIONS

To our knowledge, this is the first report of PEPVM with an autoantibody to an approximately 48-kDa RPE protein, but previous reports have demonstrated autoantibodies to other RPE proteins, suggesting that autoantibody formation is an important component of PEPVM.

TRANSLATIONAL RELEVANCE

This research emphasizes the role that autoantibodies play in PEPVM. The fact that different autoantibodies appear to cause similar patterns demonstrates the heterogeneity of causes of vitelliform lesions.