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| PHOTO ESSAY |
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| Year : 2021 | Volume
: 1
| Issue : 1 | Page : 60-61 |
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Scrub typhus associated acute macular neuroretinopathy
Kiran Chandra, Simar Rajan Singh, Ramandeep Singh, Mohit Dogra
Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| Date of Submission | 13-May-2020 |
| Date of Acceptance | 01-Aug-2020 |
| Date of Web Publication | 31-Dec-2020 |
Correspondence Address:
Dr. Mohit Dogra
Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_1471_20
Keywords: Acute macular neuroretinopathy, multimodal imaging, scrub typhus
How to cite this article:
Chandra K, Singh SR, Singh R, Dogra M. Scrub typhus associated acute macular neuroretinopathy. Indian J Ophthalmol Case Rep 2021;1:60-1 |
A 53-year-old Asian Indian male presented with complaints of sudden decrease of vision in his right eye (RE) associated with a central scotoma for the last four days. He had a high-grade fever with chills for the past two weeks and was diagnosed to be suffering from scrub typhus (Weil Felix agglutination titer of >320 and a positive IgM ELISA) and was on tablet azithromycin for the same.
RE had a corrected visual acuity (CVA) of 20/80 with the absence of intraocular inflammation. Fundus examination revealed a reddish-brown teardrop shaped lesion, extending from the subfoveal to the inferior juxtafoveal region, with its apex pointing towards the fovea along with disc edema [Figure 1]a. Left eye was unremarkable. Near-infrared (NIR) reflectance delineated the hyporeflective foveal lesion [[Figure 1]b, left panel] while optical coherence tomography (OCT) demonstrated hyperreflectivity of the outer nuclear layer (ONL) with associated disruption of the ellipsoid zone (EZ) and interdigitation zone (IZ) [[Figure 1]b, right panel]. Fluorescein angiography could not be performed as he developed wheezing and hives after injection of sodium fluorescein dye. A clinical diagnosis of acute macular neuroretinopathy (AMN) secondary to scrub typhus was made. Serial NIR scans [Figure 1]c and [Figure 1]d demonstrated a decrease in hypoeflectivity while OCT revealed a reduction of ONL hyperreflectivity with restoration of the EZ and IZ and complete resolution of disc edema over two months follow-up with the CVA improving to 20/30. | Figure 1: (a) Multicolour photograph showing a reddish-brown teardrop shaped lesion (blue arrowhead). (b) NIR reflectance (left panel) delineating the hyporeflective lesion, SD-OCT line scan (right panel) showing focal hyperreflectivity of the ONL with disruption of the EZ and IZ (yellow arrowhead), suggestive of AMN along with optic disc edema. (c and d) Follow-up NIR imaging (left panel) showing decreased hyporeflectance of the lesion, SD-OCT (right panel) demonstrating gradual resolution of the ONL hyperreflectivity with the restoration of the EZ and IZ (yellow arrowheads), at 2 weeks and 2 months, respectively
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| Discussion | |  |
AMN is an ischaemic insult to the retina secondary to insufficiency of the deep capillary plexus, associated with oral contraceptive use, hypovolemia, and dehydration.[1] It has been anecdotally reported with arthropod-borne infections like dengue.[1],[2] Scrub typhus occurs secondary to tick bite in endemic regions and may cause immune-complex mediated end-organ ischaemic injury although ocular manifestations are rare.[3],[4] Imaging features of AMN are characteristic on multicolor fundus photography, NIR imaging, and OCT.[1],[5] We report a patient with AMN secondary to scrub typhus which is the such first such reported case.
Acknowledgement
The authors acknowledge the technical staff of the Retina Lab at Advanced Eye Centre, PGIMER, Chandigarh––Arun Kapil, Sushil Bhatt, and Nitin Gautam––for the help with acquiring the fundus photographs of the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Bhavsar KV, Lin S, Rahimy E, Joseph A, Freund KB, Sarraf D, et al. Acute macular neuroretinopathy: A comprehensive review of the literature. Surv Ophthalmol 2016;61:538-65.  |
| 2. | Li M, Zhang X, Ji Y, Ye B, Wen F. Acute macular neuroretinopathy in dengue fever: Short-term prospectively followed up case series. JAMA Ophthalmol 2015;133:1329-33. |
| 3. | Sharma N, Biswal M, Kumar A, Zaman K, Jain S, Bhalla A. Scrub typhus in a tertiary care hospital in North India. Am J Trop Med Hyg 2016;95:447-51. |
| 4. | Scheie HG. Ocular changes in scrub typhus; a study of 451 patients. Bull U S Army Med Dep 1946;5:423-7. |
| 5. | Salvo GD, Vaz-Pereira S, Arora R, Lotery AJ. Multicolor imaging in the diagnosis and follow up of type 2 acute macular neuroretinopathy. Eye 2017;31:127-31. |
[Figure 1]
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