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Acute retinal necrosis following chickenpox in a healthy 4 year old patient
  1. W H LEE,
  2. S J CHARLES
  1. Vitreo-Retinal Service, Royal Eye Hospital
  2. Oxford Road, Manchester M13 9WH
  1. Mr Weng H Lee whlee{at}appleonline.net

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Editor,—Originally described by Urayamaet al,1 acute retinal necrosis (ARN) is part of a continuous spectrum of necrotising herpetic retinopathies where the clinical expression is determined by the immune status of the host.2 3 We report a case of unilateral ARN complicated by retinal detachment following chickenpox. This is unusual in its severity and an extremely rare occurrence in this age group. To our knowledge, this patient represents the youngest case of chickenpox associated ARN.

CASE REPORT

A previously healthy 4 year old boy presented with total retinal detachment secondary to ARN of his left eye 6 weeks after an uncomplicated chickenpox infection. He was attending his local ophthalmologist soon after chickenpox, having been initially referred by an optometrist, where he was treated for anisometropic amblyopia. His visual acuity at that time was 6/18 right eye and 5/60 left eye, and no detachment was noted. However, 4 weeks later, visual acuity in his left eye had dramatically reduced to perception of light secondary to a retinal detachment, and he was transferred to the vitreoretinal service.

Examination revealed a dense relative afferent pupillary defect (RAPD) and panuveitis in the left eye. There was a 250° giant retinal tear, peripheral retinal necrosis, and a pale optic disc (Figs 1 and 2). The retina was completely detached. The right eye was normal.

Figure 1

Fundus drawing of left eye. Note the giant retinal tear within the necrotic retina.

Figure 2

Perioperative photograph of left eye showing total retinal detachment.

The patient underwent left vitrectomy with silicone oil tamponade and 360° endophotocoagulation. Vitreous polymerase chain reaction (PCR) was negative for herpes simplex virus (HSV) and varicella zoster virus (VZV) but positive for cytomegalovirus (CMV). A repeat CMV PCR on the same vitreous sample was negative. Magnetic resonance imaging did not show any evidence of intracranial calcification suggestive of CMV or VZV. He had IgM to VZV only. A full immunological survey was normal. This included a normal CD4 count of 1.4 × 109/l (range 1.2–2.0 × 109/l).

He was treated with systemic aciclovir and topical steroid and mydriatic following surgery. Although the operation was anatomically successful and the retinitis had resolved, acuity remained at perception of light due to optic atrophy and was unchanged at 7 months. His right eye remained normal throughout. Prophylactic treatment to the fellow eye with systemic aciclovir 400 mg by mouth twice daily is planned for 12 months.

COMMENT

Uncomplicated primary VZV infection (chickenpox) presents initially as maculopapular and later vesicular dermal eruptions without any ocular or CNS manifestations. ARN is a rare consequence this infection in the immunocompetent. Previous case reports by Matsuoet al 4 5 and Culbertson6 suggest that chickenpox associated ARN has good visual prognosis irrespective of the immune status. None of their patients had retinal detachments. However, this case had an unusually severe retinitis culminating in a total retinal detachment and a poor visual prognosis.

Determining the specific cause of ARN is important as it has implications as to the choice of antiviral therapy. CMV associated ARN has been reported in healthy individuals.7 8 This case had no risk factors, clinical feature, or serological markers of CMV infection. The first vitreous PCR for CMV DNA was thus falsely positive, as confirmed by a repeat PCR test. Since HSV studies were also negative and he had classic features of chickenpox, backed by serology; the ARN was attributed to primary VZV infection. A retinal biopsy was not performed in this case because of a clear history of chickenpox infection, although it would have been strongly considered had the patient exhibited bilateral progressive disease.

The mode of retinal infection is unclear. Possible routes include direct haematogenous spread to the retina, or indirectly to the brain with subsequent transneural spread to the eye shortly after the primary episode.6

The length of therapy is controversial. Treatment in the acute phase and prophylaxis for the fellow eye is by systemic aciclovir. However, since aciclovir is only effective against actively replicating virus, and cannot eradicate latent virus, any protective effect is debatable.9 Indeed, delayed involvement of the fellow eye may be as long as 34 years after the initial episode.10

Zoster related ARN remains largely a disease of adults despite the fact that a majority of patients acquiring chickenpox are in the paediatric age group. Before this case, only two patients aged 6 years and 13 years were reported.6 10 Since chickenpox associated ARN is extremely rare in children, it would not be justified to treat them prophylactically. However the physician should be aware of the possibility of ARN soon after chickenpox infection. Early detection of ARN and prompt treatment are required to reduce the risk of severe visual loss.

References

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