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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 511-513

A rare case of bilateral retrobulbar neuritis and retinal vasculitis following antirabies vaccination


Department of Ophthalmology, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Submission29-Jun-2021
Date of Acceptance23-Nov-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
C K Anusha
Department of Ophthalmology, Amrita Institute of Medical Sciences, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1751_21

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  Abstract 


A 33-year-old female presented with sudden painless blurring of vision in both eyes. She gave a history of dog bite and had received two doses of intradermal anti-rabies vaccination 2 weeks prior to the onset of symptoms. Ophthalmological evaluation showed bilateral retrobulbar neuritis, superior nasal field defects in the right eye and vasculitis, and temporal hemianopia in the left eye. Extensive laboratory investigations ruled out all underlying infections, connective tissue disorders, and systemic vasculitis. Good response to pulse steroid therapy was noted. To our knowledge, this is the first case report of retrobulbar neuritis with retinal vasculitis following chick embryo cell-derived anti-rabies vaccination.

Keywords: Anti-rabies vaccination, retinal vasculitis, retrobulbar neuritis


How to cite this article:
Pillai GS, Anusha C K, Rasheed R, Radhakrishnan N, Kandula P. A rare case of bilateral retrobulbar neuritis and retinal vasculitis following antirabies vaccination. Indian J Ophthalmol Case Rep 2022;2:511-3

How to cite this URL:
Pillai GS, Anusha C K, Rasheed R, Radhakrishnan N, Kandula P. A rare case of bilateral retrobulbar neuritis and retinal vasculitis following antirabies vaccination. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 26];2:511-3. Available from: https://www.ijoreports.in/text.asp?2022/2/2/511/342899



Involvement of optic nerve and retinal vasculature after anti-rabies vaccination is extremely rare. Neurological complications are usually seen with sheep brain vaccines but can be rarely seen after chick embryo cell vaccines.[1] The antigenicity of the nerve tissue anti-rabies vaccine due to the presence of animal cerebral tissue is presumed to be responsible for optic neuritis after anti-rabies vaccine.[2] We report the case of a 33-year-old female who developed bilateral retrobulbar neuritis and left eye retinal vasculitis 2 weeks after receiving the second dose of chick embryo cell-derived anti-rabies vaccination.


  Case Report Top


A 33-year-old lady with no comorbidities presented with bilateral sudden onset blurring of vision in the left side of her visual field. She gave a history of being bitten by a stray dog 2 weeks earlier for which she was administered two doses (day 0 and day 3) of intradermal anti-rabies vaccination. Her best-corrected visual acuity at presentation was 20/20 in both eyes. Left eye showed grade 2 relative afferent pupillary defect (RAPD); rest of the anterior segment was normal in both eyes with no cells or flare. Red desaturation test was altered in the left eye.

Dilated fundus showed clear media with normal optic disc in both eyes [Figure 1]a and [Figure 1]b and mild perivascular cuffing of inferotemporal vessels suggestive of vasculitis in the left eye [Figure 1]b. Fundus fluorescein angiography (FFA) was normal in the right eye [Figure 1]c and revealed patchy areas of fuzzy hyperfluorescence along the superior and inferior temporal arcades in the left eye [Figure 1]d. Humphrey field analysis 30-2 (undilated eyes) demonstrated superonasal scotomas in the right eye [Figure 2]a and temporal hemianopia in the left eye [Figure 2]b. Thus, the diagnosis of bilateral retrobulbar neuritis and left eye retinal vasculitis was made.
Figure 1: Fundus photo showing normal optic disc and vessels in the right eye (a), normal optic disc with minimal perivascular cuffing along the inferotemporal arcade in the left eye (b), normal fundus fluorescein angiography of the right eye (c), Late venous phase of fundus fluorescein angiography showing diffuse, fuzzy hyperfluorescence with mild leakage from the superior and inferotemporal vessels of the left eye (d)

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Figure 2: Humphrey visual fields (30-2) at presentation (a and b), at 2 weeks post treatment (c and d), at 1 month post treatment (e and f)

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Keeping an autoimmune or infective etiology in mind, extensive workup was done. She had normal blood counts, biochemistry profile, and erythrocyte sedimentation rate. The cerebrospinal fluid examination showed normal constituents and normal pressure, and there was no oligoclonal bands. Axial T2-weighted magnetic resonance imaging (MRI) of the brain and optic nerve was normal. Chest X-ray and Mantoux test were within normal limits. Initial visual evoked potential (VEP) showed prolonged P100 latency (114 ms) in both eyes and decreased amplitude in the left eye (right eye: 6.9 μV, left eye: 3.7 μV).

She received intravenous methylprednisolone 1 gm/day for 5 days followed by a tapering dose of oral steroids over 2 weeks. She became symptomatically better with significant improvement in visual fields during further follow-ups [Figure 2]c,[Figure 2]d,[Figure 2]e,[Figure 2]f.


  Discussion Top


Neurologic complications occurring after anti-rabies vaccination are reported, albeit extremely rarely. The complications reported are encephalitis, myelitis, encephalomyelitis, and cranial nerve palsies limited to facial, oculomotor, glossopharyngeal, and vagus nerves.[3] Involvement of the optic nerve is extremely rare and is generally seen as a part of acute disseminated encephalomyelitis (ADEM).[4] A single case of neurological illness simulating Guillain–Barre syndrome after getting vaccinated with an anti-rabies vaccine derived from purified chick embryo cells has been reported.[1] Our patient received two doses (day 0 and 3) of chick embryo cell anti-rabies vaccination, 2 weeks following which visual symptoms were noticed. Onset of symptoms usually occurs 1–3 weeks after vaccination.[4] The mechanism thought to be responsible is an immune-complex-mediated vascular injury with consequent blood-brain barrier and blood–retinal barrier impairment, which allows lymphocytes committed to specific viral antibodies synthesized elsewhere to enter the brain, producing inflammation and optic nerve involvement.[4] Only a few cases of isolated optic neuritis have been reported after anti-rabies vaccination.[5],[6],[7] The visual field defect in retrobulbar neuritis is typically characterized as a central scotoma. However, in the optic neuritis treatment trial by Keltner JL et al.,[8] almost all types of visual field defects were noticed, including diffuse vision loss, altitudinal, arcuate, cecocentral defects, and hemianopic (4.2%) as seen in our patient. Although good spontaneous recovery is reported, pulse steroids speed up the recovery, as was the case with our patient. Another case report showed bilateral optic neuritis following four doses of chick embryo cell-derived anti-rabies vaccination on alternate days, concluding that the accelerated dosing regimen (the correct regimen being vaccinations on days 0, 3, 7, and 14) may have contributed to enhanced vaccine antigenicity, which triggered the immune system in developing optic neuritis.[6] Neuroparalytic complications although rare are observed after semple's vaccination (contains highly antigenic sheep brain tissue).[6] As the brain tissue derived vaccine and perhaps the chick embryo derived vaccine might be the cause of such complications in view of their antigenicity, recombinant vaccines may offer a solution to this problem.


  Conclusion Top


This case reports retinal vasculitis for the first time after purified chick embryo cell-derived anti-rabies vaccination. Optic nerve involvement has been previously described after the anti-rabies vaccine. Visual field disturbances should never be neglected despite having 20/20 visual acuity. Vaccination, however, remains advisable despite the potential ocular complications in view of their rarity and good visual prognosis. Recombinant vaccines may reduce the occurrence of such complications.

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.
Chakravarty A. Neurologic illness following post-exposure prophylaxis with purifiled chick embryo cell antirabies vaccine. J Assoc Physicians India 2001;49:927-8.  Back to cited text no. 1
    
2.
Fenichel GM. Neurological complications of immunization. Ann Neurol 1982;12:119-28.  Back to cited text no. 2
    
3.
Stevenson VL, Acheson JF, Ball J, Plant GT. Optic neuritis following measles/rubella vaccination in two 13-year-old children. Br J Ophthalmol 1996;80:1110-1.  Back to cited text no. 3
    
4.
Kulkarni V, Nadgir D, Tapiawala S, Malabari A, Kalgikar A, Kela R, et al. Biphasic demyelination of the nervous system following anti-rabies vaccination. Neurol India 2004;52:106-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Saxena R, Sethi HS, Rai HK, Menon V. Bilateral neuro-retinitis following chick embryo cell anti-rabies vaccination--A case report. BMC Ophthalmol 2005;5:20.  Back to cited text no. 5
    
6.
Agarwal A, Garg D, Goyal V, Pandit AK, Srivastava AK, Srivastava MP. Optic neuritis following anti-rabies vaccine. Trop Doct 2020;50:85-6.  Back to cited text no. 6
    
7.
Gupta V, Bandyopadhyay S, Bapuraj JR, Gupta A. Bilateral optic neuritis complicating rabies vaccination. Retina 2004;24:179-81.  Back to cited text no. 7
    
8.
Keltner JL, Johnson CA, Spurr JO, Beck RW. Baseline visual field profile of optic neuritis: The experience of the optic neuritis treatment trial. Arch Ophthalmol 1993;111:231–4.  Back to cited text no. 8
    


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