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Case Report: Varicella-zoster Encephalitis with Acute Retinal Necrosis and Oculomotor Nerve Palsy.
Optom Vis Sci. 2019 05; 96(5):367-371.OV

Abstract

SIGNIFICANCE

Varicella-zoster virus is a common cause of morbidity and vision loss in patients worldwide. It can affect any structure of the eye, from keratitis to acute retinal necrosis. Rapid diagnosis and treatment significantly improve clinical outcomes and quality of life.

PURPOSE

The purpose of this study was to demonstrate a case where urgent referral to the emergency department was required to treat a patient with disseminated herpes zoster infection.

CASE REPORT

This is a rare case of varicella-zoster virus encephalitis in a 70-year-old immunocompetent white man who initially presented to the eye clinic for vertical diplopia and floaters. He also had prior thoracic dermatomal rash, followed by new-onset headaches and cerebellar ataxia. Examination revealed a partial oculomotor nerve palsy in the right eye with bilateral optic disc edema and areas of retinitis consistent with acute retinal necrosis in both eyes. Polymerase chain reaction analysis of his aqueous humor and cerebrospinal fluid confirmed an active zoster infection. He received combination systemic and intravitreal antiviral medication until his retinitis resolved but required adjustments for recalcitrant disease and drug-induced nephrotoxicity. While on maintenance dosing of oral valacyclovir, he experienced reactivation in the form of bilateral vasculitis, which was successfully managed once restarting therapeutic oral dosing.

CONCLUSIONS

This case describes a successful clinical course of acute retinal necrosis with strategies for its treatment in the setting of varicella-zoster encephalitis. Antiviral medication should be given as soon as possible, as prompt treatment has been shown to improve patient outcomes, although prognosis is typically poor in these cases. Multiple specialists are often needed to address different clinical challenges, including central nervous system involvement, viral strain resistance, disease reactivation, and drug toxicity.

Authors+Show Affiliations

No affiliation info availableDepartment of Ophthalmology and Visual Science, University of Chicago Medicine and Biological Sciences, Chicago, Illinois *scquan@bsd.uchicago.edu.

Pub Type(s)

Case Reports
Journal Article

Language

eng

PubMed ID

31046020

Citation

Quan, Steven Charles, and Dimitra Skondra. "Case Report: Varicella-zoster Encephalitis With Acute Retinal Necrosis and Oculomotor Nerve Palsy." Optometry and Vision Science : Official Publication of the American Academy of Optometry, vol. 96, no. 5, 2019, pp. 367-371.
Quan SC, Skondra D. Case Report: Varicella-zoster Encephalitis with Acute Retinal Necrosis and Oculomotor Nerve Palsy. Optom Vis Sci. 2019;96(5):367-371.
Quan, S. C., & Skondra, D. (2019). Case Report: Varicella-zoster Encephalitis with Acute Retinal Necrosis and Oculomotor Nerve Palsy. Optometry and Vision Science : Official Publication of the American Academy of Optometry, 96(5), 367-371. https://doi.org/10.1097/OPX.0000000000001370
Quan SC, Skondra D. Case Report: Varicella-zoster Encephalitis With Acute Retinal Necrosis and Oculomotor Nerve Palsy. Optom Vis Sci. 2019;96(5):367-371. PubMed PMID: 31046020.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Case Report: Varicella-zoster Encephalitis with Acute Retinal Necrosis and Oculomotor Nerve Palsy. AU - Quan,Steven Charles, AU - Skondra,Dimitra, PY - 2019/5/3/entrez PY - 2019/5/3/pubmed PY - 2020/1/18/medline SP - 367 EP - 371 JF - Optometry and vision science : official publication of the American Academy of Optometry JO - Optom Vis Sci VL - 96 IS - 5 N2 - SIGNIFICANCE: Varicella-zoster virus is a common cause of morbidity and vision loss in patients worldwide. It can affect any structure of the eye, from keratitis to acute retinal necrosis. Rapid diagnosis and treatment significantly improve clinical outcomes and quality of life. PURPOSE: The purpose of this study was to demonstrate a case where urgent referral to the emergency department was required to treat a patient with disseminated herpes zoster infection. CASE REPORT: This is a rare case of varicella-zoster virus encephalitis in a 70-year-old immunocompetent white man who initially presented to the eye clinic for vertical diplopia and floaters. He also had prior thoracic dermatomal rash, followed by new-onset headaches and cerebellar ataxia. Examination revealed a partial oculomotor nerve palsy in the right eye with bilateral optic disc edema and areas of retinitis consistent with acute retinal necrosis in both eyes. Polymerase chain reaction analysis of his aqueous humor and cerebrospinal fluid confirmed an active zoster infection. He received combination systemic and intravitreal antiviral medication until his retinitis resolved but required adjustments for recalcitrant disease and drug-induced nephrotoxicity. While on maintenance dosing of oral valacyclovir, he experienced reactivation in the form of bilateral vasculitis, which was successfully managed once restarting therapeutic oral dosing. CONCLUSIONS: This case describes a successful clinical course of acute retinal necrosis with strategies for its treatment in the setting of varicella-zoster encephalitis. Antiviral medication should be given as soon as possible, as prompt treatment has been shown to improve patient outcomes, although prognosis is typically poor in these cases. Multiple specialists are often needed to address different clinical challenges, including central nervous system involvement, viral strain resistance, disease reactivation, and drug toxicity. SN - 1538-9235 UR - https://www.unboundmedicine.com/medline/citation/31046020/Case_Report:_Varicella_zoster_Encephalitis_with_Acute_Retinal_Necrosis_and_Oculomotor_Nerve_Palsy_ L2 - http://dx.doi.org/10.1097/OPX.0000000000001370 DB - PRIME DP - Unbound Medicine ER -