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Optical neuropathy due to inhaled cocaine, causality or chance
Neuropatía óptica secundaria a consumo de cocaína inhalada. Causalidad o casualidad
J. Escolano-Serrano
, C.E. Monera-Lucas, I.M. Moreno-Escudero, D. Romero-Valero, C. Fernández-Martínez, J.J. Martínez-Toldos
Corresponding author
Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, Spain
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Escolano-Serrano, C.E. Monera-Lucas, I.M. Moreno-Escudero, D. Romero-Valero, C. Fernández-Martínez, J.J. Martínez-Toldos" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Escolano-Serrano" "email" => array:1 [ 0 => "jaime.escolano.serrano@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C.E." "apellidos" => "Monera-Lucas" ] 2 => array:2 [ "nombre" => "I.M." "apellidos" => "Moreno-Escudero" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Romero-Valero" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Fernández-Martínez" ] 5 => array:2 [ "nombre" => "J.J." "apellidos" => "Martínez-Toldos" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, Spain" "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" => "Neuropatía óptica secundaria a consumo de cocaína inhalada. Causalidad o casualidad" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1964 "Ancho" => 1674 "Tamanyo" => 253762 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nuclear magnetic resonance in T2 sequence showing inflammatory changes in the mucosa of the paranasal sinuses (maxillary and frontal) as well as occupation of the sphenoid sinus.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The presence of optic nerve dysfunction signs, including diminished visual acuity (VA), presence of relative afferent pupil defect (RAPD), dyschromatopsia, diminished sensitivity to light intensity or to contrast and visual field defects in a young adult, together with the funduscopic findings of an optic nerve with edema is relatively frequent in usual clinical practice and indicates the presence of optic neuropathy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In these cases, differential diagnostic is complex and extensive and includes analysis of inflammatory, ischemic, toxic, traumatic, infiltration and compressive causes among others.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In some cases these etiologies can overlap hindering the identification of a single factor as trigger for the condition.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A clinic case is presented of a patient who developed clinic of optic nerve compromise with complex etiology due to exhibiting signs common to several optic neuropathy entities.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case</span><p id="par0020" class="elsevierStylePara elsevierViewall">Male, 44, who referred diminished VA with 2 days evolution in the right eye (RE). Personal history includes cocaine consumption, with the last intake 24 h prior to clinic onset.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ophthalmological examination showed VA of 0.05 in RE and 1 in the left eye (LE). Anterior pole examination with biomicroscopy was entirely normal in both eyes with the exception of the presence of RAPD in the RE. Funduscopy showed edema in the right papilla with congestive appearance and diffuse edges (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>-A), whereas the rest of the posterior pole examination in both eyes was normal (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>-B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Due to the patient’s clinic, urgent blood analysis was requested including biochemistry, hemogram and coagulation, which produced the only finding of discrete and nonspecific elevation of acute phase reactants. Other tests included strict control of arterial pressure and cranial computerized action tomography (CT) with normal results.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It was decided to admit the patient to the hospital for administration of intravenous corticoid treatment (large methylprednisolone boluses during 5 days, subsequently initiating a descending administration pattern).</p><p id="par0040" class="elsevierStylePara elsevierViewall">During admission, a blood test with self immunity, thrombophilia and serology was requested as well as spinal nuclear magnetic resonance (NMR) and thorax–abdominal, pelvis CT that did not produce significant findings. However, the encephalic NMR showed occupation of the sphenoid and sinus and thickening of the mucosa of the maxillary and frontal sinuses (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Visual evoked potentials (VEP) showed a demyelinizing slight compromise of the RE visual pathway. A visual field test was conducted, which showed generalized loss of sensitivity, predominantly in the RE (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A–B). The patient declined submitting to a lumbar puncture.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Five days after beginning corticoid treatment the patient was reassessed and showed VA of 1 in both eyes and less congestive and edematic appearance of the right optic nerve (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>-<span class="elsevierStyleSmallCaps">C</span>), with the rest of the examination being normal (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>-D). The final evolution of the patient was positive, with VA remaining stable and optic nerve inflammation progressively resolving.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Cocaine is a natural alkaloid derived from <span class="elsevierStyleItalic">erytroxilon coca</span>, the mechanism action of which is based on its sympathomimetic effect.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Systemic effects (tremor, tachycardia) and nasal effects (local vasoconstriction, secondary ischemia and necrosis of soft and bone tissues)<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–7</span></a> are frequent. However, ophthalmological pathology secondary to the use of cocaine is less known. The literature includes descriptions of corneal epithelial defect due to cocaine toxicity for the corneal epithelium as well as infectious keratitis,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8</span></a> endophthalmitis,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> diplopia,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> hemorrhagic anterior optic neuritis<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> to the extent that the role of cocaine was proposed as a potential trigger for optic neuromyelitis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Due to the fact that the patient of this clinic case is young, differential diagnostics should include optic neuritis as the main diagnostic possibility. However, history of inhaled consumption of cocaine should not be dismissed because it has been related to optic neuropathy clinic.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–7</span></a> In addition, and even though the patient did not exhibit typical cardiovascular risk factors or other signs of classic evolution of these entities, anterior ischemic optic neuropathy and papillophlebitis should also be present in the baseline differential diagnostic considering patient sex and age.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Optic neuritis is a relatively frequent pathology in the young population. The classic diagnostic criteria of this pathology such as unilateral sudden onset of clinic, ocular pain, age between 15 and 45 as well as the absence of other different size of optic nerve edematization in funduscopy were all found in the present patient. In addition, finding a visual pathway demyelinizing pattern observed in VEP reinforced the diagnostic suspicion of a typical optic neuritis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">However, neuroimaging tests revealed an inflammatory process on the mucosa of the paranasal sinuses, probably related to the consumption of inhaled cocaine. Due to the close anatomical relationship between the orbit cavity and the sinus content, said process could extend due to proximity and compromise intraorbital structures,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–7</span></a> compressing the optic nerve vascular bundle, compromising the irrigation and transmission of electrical impulses to give rise to edematization thereof and significant VA impairment.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> Even though it is true that, in contrast with previously published cases, no bone-osteolysis compromise was found that could communicate the sinusoidal contents with the orbital cavity,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–7</span></a> the adjacency of both spaces, together with the presence of high concentration of inflammatory cytokins, could account for the optic nerve compromise even without bone dehiscence that could communicate both cavities.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0070" class="elsevierStylePara elsevierViewall">A precise identification of the type of optic neuropathy endured by the present patient was a complex task because optic neuritis as well as optic neuropathy secondary to the use of inhaled cocaine are plausible diagnostics. However, due to the prevalence of the cocaine inhaling habit in the young population, it constitutes an option to be considered is the possibility of a casual coincidence of both entities in the present patient.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0075" class="elsevierStylePara elsevierViewall">This paper has not received specific funding from agencies of the public or private sectors, or from nonprofit entities.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interests</span><p id="par0080" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1371337" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1260324" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1371338" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1260325" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-01-19" "fechaAceptado" => "2020-04-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1260324" "palabras" => array:4 [ 0 => "Neuritis" 1 => "Papillitis" 2 => "Sinusitis" 3 => "Cocaine" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1260325" "palabras" => array:4 [ 0 => "Neuritis" 1 => "Papilitis" 2 => "Sinusitis" 3 => "Cocaína" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A 44-year-old man, active cocaine consumer, who refered decrease in visual acuity in the right eye in 24 h of evolution, being 0,05 in that eye and 1 in the left eye. The examination showed a relative afferent pupil defect and a swelling head of optic nerve. The systemic studies performed were normal, except the nuclear magnetic resonance of the brain that showed a thickening of the maxillary and frontal sinus mucosa, compatible with sinusitis. Hospital admission and the start of intravenous corticosteroid treatment were decided, with a favorable evolution, a visual acuity of unity in both eyes and an anatomical improvement of the optic nerve head. Due to the medical history of the patient and the assessment of other plausible alternative diagnoses, we establilshed the diagnosis of optical neuropathy due to inhaled cocaine abuse.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Varón de 44 años, consumidor activo de cocaína, que consultó por disminución de agudeza visual en el ojo derecho de 24 h de evolución, siendo de 0,05 en dicho ojo y de 1 en el ojo izquierdo. La exploración reveló la presencia de un defecto pupilar aferente relativo y una papila edematizada en el ojo derecho. Los estudios sistémicos realizados se encontraban dentro de la normalidad salvo la resonancia magnética nuclear encefálica que mostró un engrosamiento de la mucosa de los senos maxilares y frontales compatibles con una sinusitis. Se decidió ingreso hospitalario e inicio de tratamiento corticoideo intravenoso, presentando una evolución favorable, una agudeza visual de unidad en ambos ojos y una mejoría anatómica de la cabeza del nervio óptico. Dados los antecedentes del paciente y tras valorar otros diagnósticos alternativos plausibles se planteó el diagnóstico de Neuropatía óptica secundaria al consumo de cocaína inhalada.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Escolano-Serrano J, Monera-Lucas CE, Moreno-Escudero IM, Romero-Valero D, Fernández-Martínez C, Martínez-Toldos JJ. Neuropatía óptica secundaria a consumo de cocaína inhalada. Causalidad o casualidad. Arch Soc Esp Oftalmol. 2020. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.oftal.2020.04.006">https://doi.org/10.1016/j.oftal.2020.04.006</span></p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1698 "Ancho" => 1674 "Tamanyo" => 259231 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Edematized appearance with diffused RE papilla edges at diagnostic. (B) LE papilla without pathological findings at diagnostic. (C) Improvement of RE papilla appearance after the administration of intravenous corticoid treatment, showing better defined edges and less congestion. (D) LE papilla without changes after administering treatment.</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" => 1964 "Ancho" => 1674 "Tamanyo" => 253762 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nuclear magnetic resonance in T2 sequence showing inflammatory changes in the mucosa of the paranasal sinuses (maxillary and frontal) as well as occupation of the sphenoid sinus.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 932 "Ancho" => 2175 "Tamanyo" => 199245 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A–B) Campimetry: generalized sensitivity reduction, predominantly in RE.</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:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oftalmología clínica Octava edición" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B. 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