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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 667-669

Acute posterior multifocal placoid pigment epitheliopathy following human papilloma virus vaccination


Baskent University Istanbul Hospital, Department of Ophthalmology, Istanbul, Turkey

Date of Submission21-Nov-2020
Date of Acceptance16-Mar-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Rengin Aslihan Kurt
Baskent University Istanbul Hospital, Department of Ophthalmology, Oymac. Sokak No:7 34662 Altunizade/ Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3214_20

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  Abstract 


A thirty-five-year-old female patient presented with bilateral decreased vision and scotomas in her visual field in both eyes, two weeks after a second dose of human papilloma virus vaccination. After detailed ophthalmological examination she was diagnosed with APMPPE. Due to the visual deterioration shortly after the diagnosis, she was treated with oral prednisolone 1mg/kg. Her visual acuity improved to 20/32 in the right eye and 20/25 in the left eye in the first week, to 20/20 in both eyes in the first month of treatment. Despite rare, HPV vaccination may cause posterior uveitis in form of APMPPE.

Keywords: Acute posterior multifocal placoid pigment epitheliopathy, human papilloma virus vaccination, vaccine associated uveitis


How to cite this article:
Kurt RA. Acute posterior multifocal placoid pigment epitheliopathy following human papilloma virus vaccination. Indian J Ophthalmol Case Rep 2021;1:667-9

How to cite this URL:
Kurt RA. Acute posterior multifocal placoid pigment epitheliopathy following human papilloma virus vaccination. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 26];1:667-9. Available from: https://www.ijoreports.in/text.asp?2021/1/4/667/327666



Immunization through vaccination plays a critical role in the prevention of infectious diseases and prevents 2.5 million deaths from infectious diseases each year.[1] Vaccine-related uveitis has an estimated frequency of 10.5/100.000.[2] The underlying mechanism is unclear; nonspecific immune reaction, molecular mimicry, antigen-specific reactions, and effects of adjuvants are the potential etiologic factors.[3]

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare, self-limiting inflammatory chorioretinopathy, which is generally bilateral. Cream-colored placoid lesions at the level of the retinal pigment epithelium are the classical examination finding.[4],[5] In this case report, we describe a patient who presented with APMPPE after vaccination against human papillomavirus (HPV).


  Case Report Top


A 35-year-old female patient presented with decreased visual acuity, photopsias, and scotomas in both eyes for 3 days. She was otherwise healthy and denied any recent viral infections or prodromal symptoms. She had her second injection of quadrivalent HPV vaccine (Gardasil; Merck, Kenilworth, New Jersey) 2 weeks before.

On examination, best-corrected visual acuities (BCVA) were 20/25 in the right and 20/20 in the left eye. Dilated fundus examination revealed multiple cream-colored placoid lesions in the right eye [Figure 1]a. On fundus autofluorescence, hypoautofluorescent lesions with hyperautofluorescent borders were observed in both eyes, worse in the right eye [Figure 1]b. Fluorescein angiography showed early hypofluorescence followed by late hyperfluorescence in the corresponding areas in the right eye, window defect superotemporal to macula and late hyperfluorescence in the inferotemporal area in the left eye [Figure 1]c and [Figure 1]d. On spectral-domain optical coherence tomography, multiple serous elevations in the right eye and subtle outer retinal layer irregularities in the left eye were observed [Figure 1]e and [Figure 1]f.
Figure 1: (a) Color fundus photographs show multiple cream-coloured placoid lesions in the right eye. (b) On fundus autofluorescence, hypoautofluorescent lesions with hyperautofluorescent borders were observed in both eyes, worse in the right eye. (c and d) Fluorescein angiography showed early hypofluorescence followed by late hyperfluorescence in the corresponding areas in the right eye, window defect superotemporal to macula and late hyperfluorescence of inferotemporal area in the left eye. (e and f) Spectral-domain optical coherence tomography showed multiple serous elevations in the right eye and subtle outer retinal layer irregularities in the left eye

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The patient was diagnosed with APMPPE and observation was recommended. Three days later, she returned with deterioration of her vision. On examination, BCVA were 20/40 in the right eye and 20/25 in the left eye. Given the vaccination history and deterioration of vision, she was started on oral prednisolone 1 mg/kg/day. In the first week, BCVA improved to 20/32 in the right eye and 20/25 in the left eye. At month 1 BCVA were 20/20 in both eyes. One week after treatment the placoid lesions improved and 1 month after the treatment, they healed with pigmentary changes [Figure 2]a, [Figure 2]b and [Figure 3]a, [Figure 3]b OCT findings also regressed on 1-month follow-up [Figure 2]c, [Figure 2]d and [Figure 3]c, [Figure 3]d.
Figure 2: (a and b) Color fundus photography showed pigmentary changes in the right eye 1 week after the treatment. (c and d) Spectral-domain optical coherence tomography showed regression of the serous elevations in the right eye

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Figure 3: (a and b) Color fundus photography on the first month of the treatment revealed pigmentary changes in the right eye. (c and d) Spectral-domain optical coherence tomography showed outer retinal changes in the right eye

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  Discussion Top


Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) was first described by Gass[4] in 1968. It is a self-limiting posterior uveitis which affects the choriocapillaris, retinal pigment epithelium and outer retina. Patients generally show acute painless visual loss following a viral illness.[4],[5]

HPV is a viral infection which can cause cervical, vulvar, vaginal, anal precancerous lesions, cancers, and genital warts.[6] Bivalent, quadrivalent, and nonavalent HPV vaccines have been licensed until today. The FDA approved the quadrivalent HPV-vaccine against HPV 6, 11, 16, and 18 in 2006.[6] APMPPE following vaccinations like hepatitis B, meningococcus, varicella, polio, tetanus, and influenza has been reported in the literature.[3],[7]

Khalifa et al.[8] described the case of a 17-year-old woman with bilateral visual loss 3 weeks after quadrivalent HPV vaccination. Based on the initial examination findings, she was diagnosed with APMPPE. As her visual acuity in her left eye soon deteriorated to counting fingers in her left eye, the diagnosis was changed to ampiginous choroiditis. The patient was successfully treated with oral prednisone 1 mg/kg/day. No recurrence was seen during the follow up however extensive macular scarring was observed. Final BCVA was 20/50 in the right eye and 20/60 in the left eye.

Dansingani et al.[9] described a 20-year-old woman presented with bilateral acute vision deterioration 3 weeks after the second injection of quadrivalent HPV vaccine. At presentation, she had panuveitis and exudative retinal detachments resembling Harada disease and was treated with oral prednisolone 60 mg daily for 2 weeks. As she had a full recovery with a short course of corticosteroids and without any need of immune-suppressive treatment, her diagnosis was accepted as a vaccine-induced uveitis.

A very similar case was published by Ye et al.[10] A 29-year-old Asian woman presented with acute visual loss. She had bilateral multifocal submacular fluid on optical coherence tomography and was treated with oral corticosteroid and intravitreal Ozurdex injection. Although the case resembled Harada disease, it was accepted as vaccine-associated uveitis due to the quick response to steroids-as in Dansingani's case.

In Dansingani's, Ye's and our cases, the uveitis was seen after the second or third vaccination. This may be due to the sensitization with the first vaccine and development of the immune reaction after the following injections.[9],[10] Natale et al.,[11] using computer-assisted analysis, reported molecular mimicry between HPV type 16 oncoprotein and human self-proteins. HPV16 E7 protein showed extensive similarity to several human proteins which may explain the immune reaction following HPV vaccination.


  Conclusion Top


To the best of our knowledge, this is the first case of APMPPE following HPV vaccination. Our case does not prove a direct causative relationship, but we believe that vaccination may have triggered such an immune response.

There is no consensus on the treatment of APMPPE. However, steroids may be an alternative in cases with macular involvement or in atypical cases like ours. Vaccine-associated uveitis is generally mild, anterior uveitis, but more severe forms like APMMPE, ampiginous choroiditis, and VKH like posterior uveitis may be seen. That is why it is critical to ask all patients with uveitis for a recent vaccine history.

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 Top

1.
World Health Organization. Assessment Report of the Global Vaccine Action Plan. Available from: https://www.who.int/ immunization/global_vaccine_action_plan/en/. 2020.  Back to cited text no. 1
    
2.
Klein NP, Ray P, Carpenter D, Hansen J, Lewis E, Fireman B, et al. Rates of autoimmune diseases in Kaiser Permanente for use in vaccine adverse event safety studies. Vaccine 2010;28:1062-8.  Back to cited text no. 2
    
3.
Cunningham ET Jr, Moorthy RS, Fraunfelder FW, Zierhut M. Vaccine-associated uveitis. Ocul Immunol Inflamm 2019;27:517-20.  Back to cited text no. 3
    
4.
Gass JD. Acute posterior multifocal placoid pigment epitheliopathy. Arch Ophthalmol 1968;80:177-85.  Back to cited text no. 4
    
5.
Jones NP. Acute posterior multifocal placoid pigment epitheliopathy. Br J Ophthalmol 1995;79:384-9.  Back to cited text no. 5
    
6.
Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER; Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP). Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007;56:1-24.  Back to cited text no. 6
    
7.
Kraemer LS, Montgomery JR, Baker KM, Colyer MH. Acute posterior multifocal placoid pigment epitheliopathy after immunization with multiple vaccines. Retin Cases Brief Rep 2020. doi: 10.1097/ICB.0000000000000959.  Back to cited text no. 7
    
8.
Khalifa YM, Monahan PM, Acharya NR. Ampiginous choroiditis following quadrivalent human papilloma virus vaccine. Br J Ophthalmol 2010;94:137-9.  Back to cited text no. 8
    
9.
Dansingani KK, Suzuki M, Naysan J, Samson CM, Spaide RF, Fisher YL. Panuveitis with exudative retinal detachments after vaccination against human papilloma virus. Ophthalmic Surg Lasers Imaging Retina 2015;46:967-70.  Back to cited text no. 9
    
10.
Ye H, Feng H, Zhao P, Fei P. Case report: Posterior uveitis after divalent human papillomavirus vaccination in an Asian female. Optom Vis Sci 2020;97:390-4.  Back to cited text no. 10
    
11.
Natale C, Giannini T, Lucchese A, Kanduc D. Computer-assisted analysis of molecular mimicry between human papillomavirus 16 E7 oncoprotein and human protein sequences. Immunol Cell Biol 2000;78:580-5.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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