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About 3 cases of post-acute retinopathy of chikungunya fever
A propósito de 3 casos con retinopatía posterior a fase aguda de fiebre por chikungunya
M.A. Carrillo-Soto
, A.S. Montoya-Valladares
Corresponding author
Clínica de retinovascular, Instituto de Ciencias de la Visión del Comité pro-Ciegos y Sordos de Guatemala, Hospital de ojos y oídos Dr. Rodolfo Robles Valverde, Guatemala, Guatemala
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Montoya-Valladares" "autores" => array:2 [ 0 => array:4 [ "nombre" => "M.A." "apellidos" => "Carrillo-Soto" "email" => array:1 [ 0 => "macsoftalmo@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A.S." "apellidos" => "Montoya-Valladares" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Clínica de retinovascular, Instituto de Ciencias de la Visión del Comité pro-Ciegos y Sordos de Guatemala, Hospital de ojos y oídos Dr. Rodolfo Robles Valverde, Guatemala, Guatemala" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "A propósito de 3 casos con retinopatía posterior a fase aguda de fiebre por chikungunya" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 764 "Ancho" => 905 "Tamanyo" => 76573 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Venous obstruction in right eye with cottony exudates and slight vitritis in patient with chikungunya.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patient 1</span><p id="par0005" class="elsevierStylePara elsevierViewall">Female, 44, visited the Retina and Vitreous clinic with a 2-week history of diminishing visual acuity. Visual acuity in right eye was 0 (in logMAR scale) and hand movements in the left eye. Slit lamp examination did not evidence anomalies, while hemovitreous grade 2 was observed in the ocular fundus. The patient referred joint pain with 3 weeks evolution associated with fever. Serology was positive for IgM and IgG for chikungunya. It was decided to perform left eye vitrectomy plus panphotocoagulation. Current visual acuity of left eye is 0 (logMAR scale) and no clinical sequelae can be observed.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Patient 2</span><p id="par0010" class="elsevierStylePara elsevierViewall">Female, 17, with 2 days history of visual acuity decline in right eye with 2 days evolution. Right eye visual acuity (in logMAR scale) was 0.7 and in 0 in the left eye. Slit lamp examination did not evidence anomalies. The right eye fundus exhibited flaming hemorrhages due to central retinal vein obstruction associated with soft exudates and vitritis+ (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient referred articular pain and fever with one week evolution. Serology was positive for IgM and IgG of chikungunya. Due to the ocular condition, it was decided to initiate treatment with prednisone 50 mg daily. The treatment dose was gradually reduced to 5 mg daily. Two months later the patient had a visual acuity (in logMAR scale) of 0 in right eye and complete resolution of the hemorrhagic and inflammatory clinic.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient 3</span><p id="par0015" class="elsevierStylePara elsevierViewall">Male, 32, with 5 days history of diminishing visual acuity in left eye. Patient presented with fever (38 °C) and generalized pain during consultation. Visual acuity (in logMAR scale) in right eye was 0.1 and 0.8 in left eye. Slit lamp examination did not evidence anomalies. Ocular fundus examination evidenced effacement of the optic nerve associated with bleeding in the eye and peripheral flaming hemorrhages and periphlebitis in both the temporal and nasal arches. In addition, at the parafoveal level an area of focal choroiditis was observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Serology was positive for IgM and IgG of chikungunya. Systemic treatment was initiated with oral acetaminophen 500 mg every 6 h and prednisone 50 mg per day. Steroid treatment was gradually reduced to 5 mg per day in the eighth week and was suspended in the tenth week. The patient exhibited segmental optical atrophy, resulting in a scotoma in the temporal visual field and visual acuity (in logMAR scale) of 0.1 with best correction.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Ocular expressions of chikungunya can occur during the acute period of the disease as in patient 3 and after the acute period as in patients 1 and 2.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Retinitis due to chikungunya is usually accompanied by vitritis and vascular alterations, in addition to edema of both the retinal and the optic nerve.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> In the present cases an inflammatory condition was observed in the second patient, so it was decided to use systemic steroids, which caused better clinical and symptomatic results in both. In patient 1 the obstructive condition was more severe than the inflammatory one since central vein obstruction of the retina caused ischemia and hemovitremia that had to be surgically resolved since it did not resolve spontaneously.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is considered that the included direct compromise by the virus in the eye, as in patient 3.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Expressions after the acute period are secondary to the immune and inflammatory response to the virus. After 10 days most patients exhibit an improvement in their general health and articular pain, but some patients show reactivation of joint symptoms and development of peripheral vascular disorders, which could explain the aggressive obstructive expression of patient 1. In the case of patient 2 there could be a combination of mechanisms both by direct involvement of the virus and by inflammation and antibodies.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of the disease is reached through systemic clinical expressions and serology. It is important to mention that IgM rises from the fourth day since onset of the disease and IgG from the tenth day.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Treatment of chikungunya is mainly symptomatic. The treatment of complications is specifically focused on resolving the expressions. For example, in the case of retinitis the use of systemic steroids is suggested,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which was the treatment of choice in patients 2 and 3, while patient 1 required surgery associated with panphotocoagulation for treating ischemia secondary to venous obstruction.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1371335" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1260323" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1371336" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1260322" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Patient 1" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patient 2" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient 3" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-01-21" "fechaAceptado" => "2020-04-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1260323" "palabras" => array:7 [ 0 => "Chikungunya" 1 => "Choroiditis" 2 => "Uveitis" 3 => "Vasculitis" 4 => "Neuroretinitis" 5 => "Venous occlusions" 6 => "Haemovitreous" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1260322" "palabras" => array:7 [ 0 => "Chikungunya" 1 => "Coroiditis" 2 => "Uveítis" 3 => "Vasculitis" 4 => "Neurorretinitis" 5 => "Obstrucciones venosas" 6 => "Hemovítreo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A descriptive study is presented on a case series of 3 patients, with IgM an IgG serology diagnosis of Chikungunya in whom other metabolic, autoimmune and infectious diseases were ruled out. They presented with other ocular manifestations with vascular changes and inflammatory characteristics. They were treated at the Retinovascular and Retinal and Vitreous clinics at the “<span class="elsevierStyleItalic">Dr. Rodolfo Robles Valverde Hospital</span>” and “<span class="elsevierStyleItalic">Benemérito Comité Pro-ciegos y Sordos</span>” in Guatemala City during 2019.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Guatemala is a country with a high prevalence of vector-borne diseases, including chikungunya. In recent years cases of this disease has increased in recent years, and complications are currently seen more frequently. Within these complications, there have been reports of cases of optic neuritis, iridocyclitis, episcleritis, retinitis, uveitis, and blood dyscrasia that can affect the retina. It is important to consider these as an important differential diagnosis of ocular vascular alterations.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Este es un estudio descriptivo de serie de casos de 3 pacientes con consentimiento informado con diagnóstico por serología IgM e IgG de chikungunya y en quienes se descartaron otras enfermedades metabólicas autoinmunes e infecciosas que presentaron manifestaciones oculares con alteraciones vasculares y características inflamatorias. Fueron atendidos en las clínicas de Retinovascular y Retina y Vitreo del Hospital “Dr. Rodolfo Robles Valverde”, del Benemérito Comité Pro-Ciegos y Sordos de la ciudad de Guatemala en el transcurso del año 2019.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Guatemala es un país con una alta prevalencia de enfermedades transmitidas por vectores, dentro de las cuales se encuentra la chikungunya.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> La cual presenta aumento en la incidencia los últimos años. Dentro de las complicaciones oculares se han reportado casos de Neuritis óptica, iridociclitis, epiescleritis, retinitis y uveítis; además de discrasias sanguíneas que pueden afectar la retina.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Es importante considerarlos como un diagnóstico diferencial importante de alteraciones vasculares oculares.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Carrillo-Soto MA, Montoya-Valladares AS. A propósito de 3 casos con retinopatía posterior a fase aguda de fiebre por chikungunya. Arch Soc Esp Oftalmol. 2020. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.oftal.2020.04.010">https://doi.org/10.1016/j.oftal.2020.04.010</span></p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 764 "Ancho" => 905 "Tamanyo" => 76573 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Venous obstruction in right eye with cottony exudates and slight vitritis in patient with chikungunya.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 764 "Ancho" => 905 "Tamanyo" => 54528 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Optic nerve effacement, periphlebitis and focal choroiditis in patient with chikungunya diagnostic.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ministerio de Salud Pública y Asistencia Social. 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