Indian Journal of Ophthalmology - Case Reports

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

Acute posterior multifocal placoid pigment epitheliopathy following human papilloma virus vaccination


Rengin Aslihan Kurt 
 Baskent University Istanbul Hospital, Department of Ophthalmology, Istanbul, Turkey

Correspondence Address:
Dr. Rengin Aslihan Kurt
Baskent University Istanbul Hospital, Department of Ophthalmology, Oymac. Sokak No:7 34662 Altunizade/ Istanbul
Turkey

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.



How to cite this article:
Kurt RA. Acute posterior multifocal placoid pigment epitheliopathy following human papilloma virus vaccination.Indian J Ophthalmol Case Rep 2021;1:667-669


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 Dec 5 ];1:667-669
Available from: https://www.ijoreports.in/text.asp?2021/1/4/667/327666


Full Text



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



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}

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}{Figure 3}

 Discussion



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



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.

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