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CASE REPORT
Year : 1996  |  Volume : 44  |  Issue : 2  |  Page : 95-97

Acute retinal necrosis syndrome in HIV - positive case: The first case reported from India


1 Retina Vitreous Services, L V Prasad Eye Institute, Hyderabad, India
2 Department of Medicine, Nizam's Institute of Medical Sciences, Hyderabad, India
3 Dept. of Microbiology, Nizam's Institute of Medical Sciences, Hyderabad, India

Correspondence Address:
Subhadra Jalali
L V Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad 500034
India
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Source of Support: None, Conflict of Interest: None


PMID: 8916597

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How to cite this article:
Jalali S, Rao U, Lakshmi V. Acute retinal necrosis syndrome in HIV - positive case: The first case reported from India. Indian J Ophthalmol 1996;44:95-7

How to cite this URL:
Jalali S, Rao U, Lakshmi V. Acute retinal necrosis syndrome in HIV - positive case: The first case reported from India. Indian J Ophthalmol [serial online] 1996 [cited 2020 Feb 23];44:95-7. Available from: http://www.ijo.in/text.asp?1996/44/2/95/24596

The role of the ophthalmologist in diagnosing and managing patients with acquired immunodeficiency syndrome (AIDS) is unique. Ocular manifestations may be the presenting sign of a systemic infection in an otherwise asymptomatic human immunodeficiency virus (HIV) positive individual.[1],[2] Ocular involvement in these cases is varied and can affect almost all structures of the eye.[3] Also, ocular lesions and their response to treatment have a prognostic value. Most of the visually disabling ocular manifestations, particularly opportunistic infections occur in the AIDS phase, while the presumed HIV related asymptomatic ocular lesions occur in the earlier stages.[4] In India, HIV infection is relatively less commonly diagnosed by ophthalmologists. Rarity tends to decrease levels of suspicion and the facility of recognition of the disease among the physicians. Acute retinal necrosis syndrome (ARN) is a well defined entity with characteristic clinical picture and is caused by one of the members of the Herpes group of viruses. The condition occurs typically in otherwise healthy patients. Rarely ARN has been reported in immunosuppressed patients with AIDS.[5],[6] We report an otherwise asymptomatic HIV positive individual presenting with ARN, which to our knowledge is the first such case reported from India.


  Case report Top


A 35-year-old male presented with a history of gradual decrease in vision in both eyes of two months duration. Past history revealed that six months ago he had been treated with antitubercular treatment for cervical lymphadenopathy with a discharging sinus, which subsequently resolved.

On examination the visual acuity was counting fingers at 20cms in both eyes and the intraocular pressure was 10 mmHg by applanation tonometry in both the eyes. Slit-lamp biomicroscopy showed multiple mutton fat keratic precipitates all over the cornea in both the eyes [Figure - 1]. Anterior chamber had 1+ cells and flare, pupils were equally reacting to light, lens was clear and the vitreous had 1+ cells in both the eyes. Fundus examination after dilatation showed severe disc pallor with arterial and venous attenuation [Figure - 2]. There were large granular areas of retinal whitening in the periphery with sheathing of peripheral veins [Figure - 3]. Few areas showed retinal haemorrhages. The overlying vitreous was hazy in some areas of retinal necrosis. There were no retinal holes and no new vessels. Treatment was started with betamethasone eye drops every two hourly and cyclopentolate 1% three times a day in both the eyes for the anterior uveitis. Detailed systemic evaluation was carried out in consultation with the physician.

General physical examination showed mild anaemia with generalised, non-tender lymphadenopathy and a scar of a healed sinus in the cervical lymph nodes. There was no organomegaly.

Haemogram revealed haemoglobin: 10.7 gm %; total WBC count: 5000 cells/cumm; differential count: neutrophils 73%;lymphocytes 23%; eosinophils 3 %; and monocytes 1 % with adequate platelets. The peripheral blood film was normal. Montoux test showed no induration (anergy). The ELISA test for Hepatitis B antigen, rheumatoid factor, anti ds DNA and C reactive protein were negative. Erythrocyte sedimentation rate (ESR) was 35 mm in the first hour. The chest radiogram was normal. The ELISA test for HIV-1 antibody was reactive and was confirmed by western blot test which showed a positive reaction representing proteins GP 41, P31 and P24.

Subsequently serology for the cytomegalovirus (CMV) and Herpes simplex virus (HSV) antibody (both IgG and Ig M ) also tested positive by ELISA testing, while the titres for toxoplasmosis were negative. The circulating immune complexes were reported positive with a value of 59 mg/dl(normal < 20 mg/dl). Facilities for CD 4+ lymphocytes count were not available.

Based on the above clinical findings and investigations, he was diagnosed to have acute retinal necrosis syndrome with concurrent HIV infection. He was advised intravenous acyclovir treatment and referred to an AIDS care centre for further management.

He, however, refused any such treatment. Two weeks later he was reviewed and at that time the anterior segment inflammation had decreased. The visual acuity was 6/18 in the right eye and counting fingers at 1 meter in the left eye. The retinal lesions were showing resolution [Figure - 4] and venous perfusion had improved, though the disc was still pale with retinal arterial narrowing. At this visit the patient revealed having had multiple sexual partners including professional sex workers over the last two years. The patient was again advised to have systemic acyclovir for ARN. However, he refused any further treatment since he felt that his vision had improved, and he left against medical advice.

The patient came back 3 weeks later with a history of sudden diminution of vision in the right eye of 2 days duration. On examination, the visual acuity in the right eye was 6/24 and 6/60 in the left eye. Anterior segment was quiet.

Fundus examination showed multiple large retinal holes in the upper nasal quadrant with localised detachment in the right eye, though the areas of retinal necrosis were resolving in both the eyes. He was again advised to contact the referral AIDS care centre for treatment and possible surgery.


  Discussion Top


To our knowledge, this is the first report of acute retinal necrosis syndrome in a HIV positive individual from India. The first case of AIDS with ocular lesions, reported from India had Cytomegalovirus (CMV) retinitis along with dementia[7] and two more cases of AIDS with ocular presentation have been reported later[8] but none presented with ARN. Also two cases of ARN reported from India were not HIV related.[9]

The clinical picture in our patient was characteristic of ARN. The clinical suspicion of systemic immunosuppression in this patient was aroused because of the bilateral, severe nature of the lesions involving the vessels and the optic nerve in addition to the involvement of retinal periphery. Laboratory investigations confirmed the clinical suspicion and only later did the patient reveal having had extra-marital sexual contact with multiple heterosexual partners.

Our patient did not have any systemic symptoms of HIV infection. Ocular findings are infrequent in asymptomatic HIV-infected individuals. In the study by Jabs et al,[10] 40% of patients with AIDS-related complex and 1.3% of asymptomatic HIV patients had retinopathy though none had perivascular sheathing or infectious retinopathy.

Ocular opportunistic infections in HIV positive individuals include CMV, Cryptococcus, Mycobacterium avium-intercellulare, Candida, Pneumocystis carinii, etc.

Other retinal infections reported include toxoplasmosis, syphilis, herpes simplex and herpes zoster.[1][2][3][4]

ARN is a disease of varying severity. The American uveitis society criteria for diagnosis of ARN,[11] includes focal, well demarcated peripheral areas of retinal necrosis, rapid circumferential progression, occlusive vasculopathy with arteriolar involvement, and a prominent inflammatory reaction in the vitreous and anterior chamber. Presence of optic neuropathy supports the diagnosis.[11] Our patient had classical clinical features of ARN in the form of a granulomatous uveitis, peripheral white granular areas of retinal necrosis with few haemorrhages. Some areas of the retina also showed perivascular exudation and there was associated occlusive vasculopathy, vitreal inflammation and optic neuropathy. ARN generally occurs in normal individuals and may be mild and self-limiting, or severe.[11][12][13] However, the immunological status or extent of severity do not influence the clinical diagnosis of ARN.[11] In patients with HIV infection as in our patient, ARN tends to be severe, bilateral and with poorer visual prognosis.[5],[6],[12],[13]

ARN in HIV-positive patients occurs when they are not totally immunoincompetent as opposed to CMV retinitis which is seen in severely ill, immunosuppressed patients, often with systemic infection. [1, 2, 7-9] Large retinal holes with retinal detachment occurs within 2 months in 25-75 % of patients of ARN.[12][13] Considerable evidence points to one or more members of the herpes virus family as the cause of ARN.[5],[12]

Though systemic therapy with intravenous acyclovir can reduce the severity and duration of inflammation and prevent involvement of the other eye, the effect of such treatment on the incidence of retinal detachment and the final visual outcome is not known.[12]

The options of managing HIV infected individuals are limited in India due to lack of availability of treatment in general hospitals, fear of infection amongst health-care workers, the social stigma involved and the prohibitive cost of medical treatment. However, a high index of clinical suspicion along with a careful and pertinent systemic evaluation with timely referral is mandatory for the diagnosis of these cases which otherwise may be misdiagnosed.

 
  References Top

1.
Dugel PU, Rao NA. Ocular infections in the acquired immunodeficiency syndrome. Int Ophth Clin 33:103-127, 1993.  Back to cited text no. 1
    
2.
Rao NA. Acquired immunodeficiency syndrome and its ocular complications. Ind J Ophthalmol 42:51-63, 1994.  Back to cited text no. 2
    
3.
Biswas J, Rao NA. Diagnosis and management of ocular lesions in acquired immune deficiency syndrome. Ind J Ophthalmol 36:151-155, 1988.  Back to cited text no. 3
    
4.
Rajeev B, Rao NA. Advances in ocular pathology in AIDS. Ophthalmology Clinics Of North America, Vol. 8, 1995. Philadelphia, Saunders Company, pp. 125-141.  Back to cited text no. 4
    
5.
Chess J, Maran DM. Zoster-related bilateral acute retinal necrosis syndrome. Ann Ophthalmol 20:431-435,1988.  Back to cited text no. 5
    
6.
Friberg TR, lost BF. Acute retinal necrosis in immunosuppressed patients. Am J Ophthalmol 98:1555-1556,1984.  Back to cited text no. 6
    
7.
Lehl SS, Bambrey P, Avasthi A, et al. CMV Retinitis and Dementia in an Indian with AIDS. JL. Assoc.Phy. India. 43:136-137, 1995.  Back to cited text no. 7
    
8.
Biswas J, Madhavan HN, Badrinath SS. Ocular lesions in AIDS:A report of first two cases in India. Ind J Ophthalmol 43:69-72, 1995.  Back to cited text no. 8
    
9.
Biswas J, Madhavan HN, Gopal L, et al. Clinical features and virologic studies in viral retinitis. Ind J Ophthalmol 43:63-68, 1995.  Back to cited text no. 9
    
10.
Jabs DA, Green R, Fox R, et al. Ocular manifestations of acquired immune deficiency syndrome. Ophthalmology. 96:1092-1099, 1989.  Back to cited text no. 10
    
11.
Holland GN and the executive comittee of the American Uveitis Society. Standard diagnostic criteria for the acute retinal necrosis syndrome. Am J Ophthalmol. 117:663-667, 1994.  Back to cited text no. 11
    
12.
Culbertson WW, Atherton SS. Acute retinal necrosis and similar retinitis syndromes. Int Ophth Clin. 33:129-143, 1993.  Back to cited text no. 12
    
13.
Matsuo T, Morimoto K, Matsuo N. Factors associated with poor visual outcome in acute retinal necrosis syndrome Br J Ophthalmol. 75:450-454, 1991.  Back to cited text no. 13
    


    Figures

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



 

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