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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 670-673

Inflammatory retinal and choroidal neovascularization in a case of post-fever immune retinitis


Department of Vitreo-Retina and Uveitis, Shri Sadguru Seva Sangh Trust, Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India

Date of Submission07-Jan-2021
Date of Acceptance20-Mar-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Alok Sen
Vitreo-Retina and Uveitis Services, Shri Sadguru Seva Sangh Trust, Sadguru Netra Chikitsalaya, Chitrakoot - 210 204, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_67_21

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  Abstract 


The development of retinal and choroidal neovascularization in posterior uveitis is attributed to the angio-inflammatory drive with/without ruptures in the retinal pigment epithelium-Bruch's membrane complex. We report a unique case of a 15-year-old Asian-Indian female who developed immune retinitis post-typhoid fever along with simultaneous retinal and choroidal neovascularization. After ruling out infectious etiologies, she was initiated on a course of systemic steroids considering that the retinitis had immune-mediated pathogenesis. Subsequently, the retinitis lesion and choroidal neovascular membrane healed with scarring while the retinal neovascular complex showed fibrotic regression.

Keywords: Choroidal neovascular membrane, immune retinitis, inflammatory, post-fever, retinal neovascularization, retinitis, typhoid


How to cite this article:
Shenoy P, Kohli GM, Bhatia P, Sen A. Inflammatory retinal and choroidal neovascularization in a case of post-fever immune retinitis. Indian J Ophthalmol Case Rep 2021;1:670-3

How to cite this URL:
Shenoy P, Kohli GM, Bhatia P, Sen A. Inflammatory retinal and choroidal neovascularization in a case of post-fever immune retinitis. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 21];1:670-3. Available from: https://www.ijoreports.in/text.asp?2021/1/4/670/327648



The posterior segment manifestations of febrile illness-related immune injury have been found to present with similar constitutional features of retinitis, retinal hemorrhages, perivascular exudates with vasculitis and have shown a good response to both antibiotics and steroid therapy.[1],[2],[3] These subgroups of posterior uveitis which follow a febrile episode have collectively been labeled as post-fever retinitis taking into consideration the similarities in presentation, immune-mediated mechanism, and response to systemic steroids. Retinal neovascularization in eyes with immune-mediated retinitis has shown to regress with stabilization of inflammation.[4] Inflammatory choroidal neovascular membrane (CNVM) has been reported following infectious and noninfectious posterior uveitis.[5],[6],[7] To the best of our knowledge, their simultaneous development accompanying immune retinitis has not been reported. In this case report, we detail the clinical characteristics and treatment outcome of a case of post-typhoid fever immune retinitis with concurrent development of retinal neovascularization and CNVM.


  Case Report Top


A 15-year-old female presented with complaints of painless, progressive diminution of vision in her right eye for the past 3 weeks, with no constitutional symptoms. She had a history of fever without chills/rash 6 weeks back and was diagnosed to have typhoid fever based on a positive Widal test, for which she was treated with oral ofloxacin 200 mg twice daily for 2 weeks. On ocular examination, her best-corrected visual acuity (BCVA) was 20/1200 in the right eye and 20/20 in the left eye.

The anterior segment was unremarkable, fundus examination revealed a solitary, elevated retinitis lesion inferonasal to the fovea with associated intraretinal and subretinal hemorrhages along with clumps of hard exudates surrounding the lesion. Neovascular tufts were visualized superotemporal to the fovea and along the inferotemporal arcade [Figure 1]a.
Figure 1: The fundus picture at presentation (a) shows a solitary retinitis patch (green arrow) with surrounding hard exudates, intraretinal and subretinal hemorrhages. Two retinal neovascular complexes are visible superotemporal to the fovea and along the inferotemporal arcade. (White arrows) The OCT (b) line scan (corresponding to the white line shown in Fig. 1a) shows full-thickness retinal hyperreflectivity corresponding to the retinitis. A fusiform lesion surrounded by a cuff of SRF with hyperreflective foci and cystic spaces is indicative of a CNVM

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The optical coherence tomography (OCT) through the retinitis patch showed full-thickness retinal hyperreflectivity with loss of differentiation of the retinal layers. Additionally, a subretinal hyperreflective dome-shaped lesion was noted abutting the site of retinitis with an adjoining cuff of subretinal fluid (SRF), hyperreflective dots, and intraretinal cystic changes, suggestive of a CNVM [Figure 1]b.

On fundus fluorescein angiography the retinitis lesion appeared hypofluorescent in the early phases with subsequent hyperflouroscence due to leakage in the later phase. The areas of clinically apparent neovascular fronds revealed straightening of the vessels with hyperflouroscence and leakage suggestive of retinal neovascularization. A fine vascular complex ascribed to the site of suspected CNVM was apparent as a meshwork in the early phase which was obscured in late phases owing to profuse leakage from surrounding capillaries and new vessels [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d.
Figure 2: The fundus photograph (a) and fundus fluorescein angiography (b-d) at presentation show the retinal neovascular complex (dotted white circles). The choroidal neovascular complex (yellow arrow) is visible on fundus fluorescein angiography (b). The retinal and choroidal neovascular lesions show profuse leakage in the later phases (c and d)

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Her complete blood count was normal and systemic investigations ruling out infective causes of retinitis including Mantoux, Venereal Disease Research Laboratory test, HIV, herpes simplex virus, varicella-zoster virus, and cytomegalovirus were negative. Also, the Weil-Felix, dengue, and chikungunya tests were negative.

Considering a latent period of three weeks between fever and visual symptoms along with laboratory tests being negative for pertinent causes of infectious retinitis, a diagnosis of immune-mediated post-typhoid fever retinitis with retinal and choroidal neovascularization was made and the patient was initiated on oral steroids 1 mg/kg body weight. An intravitreal anti-vascular endothelial growth factor injection was advised, which the patient declined.

At subsequent follow-ups, the steroids were tapered weekly over a course of 6 weeks as the retinitis lesion showed regression with the consolidation of the CNVM complex on OCT. [Figure 3]a and [Figure 3]b Although the baseline OCT-Angiography (OCT-A) had poor resolution due to SRF, the follow-up OCTA delineated the neovascular complex with an internal flow signal within the outer retinal and choriocapillaris slab corresponding to the CNVM complex seen on OCT [Figure 3]c.
Figure 3: Fundus picture after 1 month (a) shows the disappearance of hemorrhages, consolidation of exudates, resolving retinitis with the appearance of fibrosis in areas of retinal neovascularization. The OCT line scan (b) shows resolution of SRF with CNVM consolidation while OCT-A shows the neovascular complex in the outer retina and choriocapillaris slab (c) (dotted yellow circles)

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Five months after the initial presentation, the BCVA had improved to 20/60. Fundus examination showed pigmentary changes at the fovea, a well-demarcated scar in the area of healed retinitis-CNVM composite with fibrosis along the inferotemporal arcade and resolving exudates. [Figure 4]a The OCT showed consolidation of the CNVM scar and retinal structural distortion in the antecedent area of retinitis while the OCTA showed a dead tree pattern of the regressed CNVM complex [Figure 4]b and [Figure 4]c.
Figure 4: Five months after the initial presentation the fundus picture (a) shows the scarred retinitis-CNVM complex (white arrow) with fibrosis of the retinal neovascularization (dotted white circles). The OCT line scan shows retinal structural distortion in the area of retinitis and a scarred CNVM complex (b) with consolidated vessels on OCT-A in the outer retina and choriocapillaris (c) (dotted yellow circles)

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  Discussion Top


The development of retinitis following typhoid fever has been attributed to an immune-mediated mechanism which remains supported by the latency in the development of retinitis lesion following the febrile episode and good response to steroids.[8],[9] Although blood culture isolation remains the modality of choice for the diagnosis of typhoid fever, the Widal test is commonly used in endemic settings.[1]

In our case, the retinitis was seen to involve the entire retinal thickness leading to enduring architectural distortion after resolution. An atypical manifestation in our case was the presence of simultaneous retinal and choroidal neovascularization accompanying retinitis. The narrative for retinal and choroidal angiogenesis in eyes with uveitis remains centered around the presence of inflammation and an accompanying angiogenic drive, with or without the presence of RPE-Bruch's membrane disruption.[5],[10]

The retinitis patch involving the entire thickness of the retina, including the outer layers, could have led to ruptures in the RPE-Bruch's membrane complex favoring the ingrowth of neovascular tissue from the choroid. The presence of significant inflammation is depicted by the profuse retinal capillary leak stimulating the angio-inflammatory drive governing the formation of inflammatory retinal neovascular tufts.

The role of corticosteroids as an anti-angiogenic agent has been demonstrated in inflammatory neovascularization including CNVM.[11] The retinal neovascularization and CNVM in our case showed a good response to oral steroids with fibrosis, complete resolution of SRF, and organization of CNVM complex, further indicating their inflammatory origin.


  Conclusion Top


Immune-mediated retinitis following typhoid fever can be complicated by retino-choroidal neovascularization. The use of systemic steroids permits the resolution of retinitis with regression of the retinal neovascularization and choroidal neovascular complex.

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.
Mahendradas P, Kawali A, Luthra S, Srinivasan S, Curi AL, Maheswari S, et al. Post-fever retinitis-Newer concepts. Indian J Ophthalmol 2020;68:1775-86.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Kawali A, Srinivasan S, Mohan A, Bavaharan B, Mahendradas P, Shetty B. Epidemic Retinitis with Macular Edema -Treatment Outcome with and without Steroids. Ocul Immunol Inflamm 2020;21:1-5.  Back to cited text no. 2
    
3.
Vishwanath S, Badami K, Sriprakash KS, Sujatha BL, Shashidhar SD, Shilpa YD. Post-fever retinitis: A single center experience from south India. Int Ophthalmol 2014;34:851-7.  Back to cited text no. 3
    
4.
Reddy S, Agarwal K, Agarwal H, Janis A. Response to comments on: Optical coherence tomography angiography in epidemic retinitis. Indian J Ophthalmol 2021;69:182.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Patel AK, Newcomb CW, Liesegang TL, Pujari SS, Suhler EB, Thorne JE, et al. Risk of retinal neovascularization in cases of uveitis. Ophthalmology 2016;123:646-54.  Back to cited text no. 5
    
6.
Baxter SL, Pistilli M, Pujari SS, Liesegang TL, Suhler EB, Thorne JE, et al. Risk of choroidal neovascularization among the uveitides. Am J Ophthalmol 2013;156:468-477.e2.  Back to cited text no. 6
    
7.
Roy R, Saurabh K, Bansal A, Kumar A, Majumdar AK, Paul SS. Inflammatory choroidal neovascularization in Indian eyes: Etiology, clinical features, and outcomes to anti-vascular endothelial growth factor. Indian J Ophthalmol 2017;65:295-300.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Relhan N, Pathengay A, Albini T, Priya K, Jalali S, Flynn HW Jr. A case of vasculitis, retinitis and macular neurosensory detachment presenting post typhoid fever. J Ophthalmic Inflamm Infect 2014;4:23.  Back to cited text no. 8
    
9.
Prabhushanker M, Topiwalla TT, Ganesan G, Appandaraj S. Bilateral retinitis following typhoid fever. Int J Retina Vitreous 2017;10;3:11.  Back to cited text no. 9
    
10.
Dhingra N, Kelly S, Majid MA, Bailey CB, Dick AD. Inflammatory choroidal neovascular membrane in posterior uveitis-pathogenesis and treatment. Indian J Ophthalmol 58:3-10.  Back to cited text no. 10
    
11.
Martidis A, Miller DG, Ciulla TA, Danis RP, Moorthy RS. Corticosteroids as an antiangiogenic agent for histoplasmosis-related subfoveal choroidal neovascularization. J Ocul Pharmacol Ther 1999;15:425-8.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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