Acute retinal necrosis caused by co-infection with multiple viruses in a natalizumab-treated patient: a case report and brief review of literature

Abstract

Background Acute retinal necrosis is considered a rare infectious uveitis. This condition is usually caused by varicella-zoster virus or herpes simplex virus. Acute retinal necrosis caused by co-infection with multiple viruses is extremely rare. Herein, we report a case of acute retinal necrosis caused by co-infection with herpes simplex virus (type I and II) and varicella-zoster virus (VZV) in a natalizumab-treated patient due to multiple sclerosis. Case presentation An adult man presented with a complaint of decreased vision of the right eye from 12 days ago. He was a known case of multiple sclerosis receiving natalizumab. Examination of the right eye revealed severe conjunctival injection, fine diffuse keratic precipitates, 3 + anterior chamber and vitreous cells, elevated intraocular pressure (26 mmHg), a blurred optic disk with hemorrhagic patches, and occlusive vasculitis plus confluent necrotizing patches in the peripheral retina compatible with diagnosis of acute retinal necrosis. He underwent anterior chamber and vitreous tap, and real-time PCR detected HSV I & II and VZV on the vitreous specimen. A second PCR showed the same result. After neurological consultation, natalizumab was discontinued and intravenous acyclovir was started followed by oral acyclovir and oral prednisolone to control the disease, which was successful. Conclusions Although rare, multiple-viral infection should be considered in the physiopathology of acute retinal necrosis, especially in immunosuppressed patients.

Neuro-ophthalmic complications of varicella-zoster virus

“…In the retina, VZV infection typically occurs as two distinct syndromes, acute retinal necrosis (ARN) with prominent intraocular inflammation in immune-competent individuals, and pauci-inflammatory progressive outer retinal necrosis (PORN) that occurs in severely immune-compromised individuals [16,17]. However, this is not absolute and there have been several reports describing ARN in immunosuppressed patients and PORN in immunocompetent patients [18,19]. Due to the high rates of retinal detachment in ARN, visual outcomes are frequently poor [20,21].…”

From Bedside to Diagnosis: The Role of Ocular Fundus in Systemic Infections

“…Detection of CMV infection in the eye, beyond its ocular implications, signals a vital alert for possible life-threatening systemic involvement, thereby underscoring the importance of ocular assessments in comprehensive patient management, especially amidst immunosuppressive conditions [47,48]. In Table 2, principal viruses, along with their ocular fundus findings, are reported [49][50][51][52][53][54]. Herpes viruses can cause serious necrotizing conditions that affect the retina.…”

Clinical Case of a Patient With Acute Retinal Necrosis

“…Известно, что ОРН развивается у соматически здоровых людей, однако чаще возникает среди лиц, страдающих иммунодепрессивными заболеваниями или получающих иммуносупрессивную терапию, встречается в любом возрасте и чаще поражает мужчин [5].…”