Commentary: Rickettsial retinitis – Direct bacterial infection or an immune-mediated response?

Ayachit, Apoorva; Joshi, Shrinivas; Sameera, VV

doi:10.4103/ijo.ijo_681_17

Cited by 6 publications

(5 citation statements)

References 9 publications

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“…As for this case in our study, visual field defect in ON eye occurred early (2 or 3 days after possible insect bite), visual acuity progressively deteriorated after sequential steroid therapy alone and doxycycline therapy alone, but gradually improved after doxycycline combined with steroid pulse therapy, and finally permanent vision and visual filed defects were left at five-month follow-up, indicating that both early direct invasion and subsequent parainfectious immune-mediated mechanism are involved in the pathogenesis of ON in this case ( 19 – 23 ).…”

Section: Discussionmentioning

confidence: 69%

“…Direct bacterial invasion, post-infectious immune−mediated inflammation, or even induction of causative ON biomarkers such as AQP-4Ab are proposed as the mechanism of ON after Orientia tsutsugamushi infection ( 18 – 24 ). Some previous investigations proposed that direct bacterial invasion might play a major role in the pathogenesis of ON based on their clinical experience of rickettsial retinitis therapy ( 18 , 19 ). However, considering that ON mostly occurred at the post-fever or recovery stage of the natural course of scrub typhus, and showed good response to steroid combined with antibiotic agents therapy, many investigators preferred an immune-mediated to a direct invasion mechanism ( 19 , 20 ).…”

Section: Discussionmentioning

confidence: 99%

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Case Report: Optic neuritis as the initial presentation of Orientia tsutsugamushi infection detected by metagenomic next-generation sequencing

Sun

Liu

2023

Front. Immunol.

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Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi infection, and typically manifested as fever, eschar, lymphadenopathy, rash, and other flu-like signs. Ocular involvement was not uncommon, and mostly occurred at post-fever or recovery stage in scrub typhus cases. We hereby report a case of scrub typhus presenting as unilateral optic neuritis (ON). A 56-year-old man going wild fishing nearly every day complained of a blurred vision and an inferior visual field defect in the right eye two or three days after an insect-bite like shin induration in his left leg. He was diagnosed as ON, and treated with dexamethasone in the local hospital. Unfortunately, his right eye vision progressively deteriorated during steroid therapy. Three days after steroid therapy ceased, he suffered from a high fever and painful subcutaneous masses in the left groin. Peripheral blood test by metagenomic next-generation sequencing (mNGS) was positive for Orientia tsutsugamushi, but negative for other pathogens. The diagnosis was then revised to scrub typhus and ON. His systemic symptoms rapidly disappeared after oral doxycycline and omadacycline therapy. However, his right eye vision continuously deteriorated to hand motion. Further serum tests for aquaporin 4-IgG antibody and myelin oligodendrocyte glycoprotein-IgG antibody were both negative, but for anticardiolipin IgM and beta-2-glycoprotein-I IgM were both positive. The patient’s right eye vision gradually improved after doxycycline combined with steroid pulse therapy. Our case indicates that ON in scrub typhus cases may present as a parainfectious inflammation, and that mNGS is a useful and valuable method for early diagnosis of scrub typhus.

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Section: Discussionmentioning

confidence: 69%

Section: Discussionmentioning

confidence: 99%

Case Report: Optic neuritis as the initial presentation of Orientia tsutsugamushi infection detected by metagenomic next-generation sequencing

Sun

Liu

2023

Front. Immunol.

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“…Empirical initiation of oral steroid in a similar case of retinitis resulted in worsening. 28 This patient responded well once the oral steroid was stopped and oral doxycycline started. 28 Though we consider most of our cases as presumed bacterial (related to Rickettsia , Lyme disease or Bartonella ), for the purpose of categorization, we have also included presumed dengue, chikungunya and West Nile fever retinitis in this group as a similar presentation may be seen following infection by these viruses.…”

Section: Discussionmentioning

confidence: 86%

An imaging-based treatment algorithm for posterior focal retinitis

et al. 2018

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Background:In this paper, our aim was to describe an imaging-based empirical approach for categorizing and initiating treatment of immunocompetent patients with posterior focal retinitis, prior to the availability of results of expensive laboratory investigations.Materials and methods:The hospital records of 13 patients with posterior focal retinitis were reviewed.Results:Of the 13 patients, 9 were women and 4 were men. The mean age was 24 ± 8 years. Based on similarities in clinical presentation and imaging, we categorized our cases into three groups with different first-line therapeutic strategies. In the first group, patients had presumed toxoplasmosis (treated with oral cotrimoxazole); in the second group, patients had presumed viral (herpetic) etiology (treated with oral valacyclovir); and in the third group, patients had presumed nonherpetic, nontoxoplasma retinitis (treated with oral doxycycline). Positive serology results included Rickettsia (two patients), Borrelia (one patient), Toxoplasma (two patients), and herpes simplex virus (one patient).Conclusion:An empirical approach for early initiation of therapy in retinitis cases based on imaging features is described.

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“…Anti-inflammatory property of anti-VEGF agents has recently been studied in experimental study of inflammatory CNVM and macular edema,[ 7 ] and a similar mechanism can play a role in ER as well. Worsening or migration of retinitis lesions after use of steroids has been reported previously,[ 1 9 10 ] and hence use of a non-steroidal agent for treatment of macular edema becomes particularly important in cases of retinitis of infective etiology.…”

Section: Discussionmentioning

confidence: 99%

Anti-vascular endothelial growth factor in the treatment of macular edema in epidemic retinitis

Kawali

Mohan

Mehta

et al. 2020

Indian J Ophthalmol

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Purpose: To study efficacy of anti-vascular endothelial growth factor (anti-VEGF) in resolution of macular edema in epidemic retinitis (ER). Methods: In this retrospective, comparative study, patients diagnosed as ER with central macular thickness (CMT) ≥ 600 μm on SD-OCT at presentation were studied. Eyes which did not receive intravitreal anti-VEGF formed group A and eyes receiving additional anti-VEGF formed group B. Eyes receiving anti-VEGF monotherapy were studied separately. Cases with subsequent OCT scans with interval of more than 20 days and cases without OCT scan at the resolution were excluded. Treatment details, visual outcome, and days to resolution of macular edema were studied. Results: Mean CMT in group A ( n = 8) was 820.1 μm (range 607-1004 μm) and in Group B ( n = 4) was 756.0 μm (range 603-1000 μm). Macular edema resolved in 34.8 days (range: 16-65) and 39.0 days (range: 21–45) in group A and B, respectively. Two eyes with anti-VEGF monotherapy recovered in 45 and 18 days, respectively. Mean corrected distance visual acuity (CDVA) at presentation in group A was 19.1 (range: 0–61) ETDRS letters and in group B was 14.3 (range: 0–35) ETDRS letters. Mean CDVA improved to 65.7 (range: 0–85) and 50.8 (range: 20–76) ETDRS letters in group A and B, respectively. Anti-VEGF monotherapy eyes improved from 35 and 46 ETDRS letters to 70 and 85 ETDRS letters, respectively. Conclusion: Additional anti-VEGF therapy has no added advantage in speed of resolution of macular edema due to ER. A randomized controlled trial with steroids sparing “anti-VEGF monotherapy” may verify our observations.

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Commentary: Rickettsial retinitis – Direct bacterial infection or an immune-mediated response?

Cited by 6 publications

References 9 publications

Case Report: Optic neuritis as the initial presentation of Orientia tsutsugamushi infection detected by metagenomic next-generation sequencing

Case Report: Optic neuritis as the initial presentation of Orientia tsutsugamushi infection detected by metagenomic next-generation sequencing

An imaging-based treatment algorithm for posterior focal retinitis

Anti-vascular endothelial growth factor in the treatment of macular edema in epidemic retinitis

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