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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 34

Bilateral retinal hemorrhages and macular edema in a patient with dengue fever associated with cerebral hemorrhage


Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India

Date of Submission05-Sep-2021
Date of Acceptance21-Sep-2021
Date of Web Publication22-Oct-2021

Correspondence Address:
Dr. Rajesh Subhash Joshi
77, Panchatara Housing Society, Manish Nagar, Somalwada, Nagpur - 440 015, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_106_21

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  Abstract 


We report a case of bilateral retinal hemorrhages with macular edema in a patient with dengue fever (DF). This patient also had cerebral hemorrhage. A 17-year-old female presented with sudden painless loss of vision in her both eyes for 2 days associated with redness of eyes. She was diagnosed having DF based on detected dengue immunoglobulin M in her blood sample. Fundus examination of both eyes showed preretinal and intraretinal hemorrhages. Optical coherence tomography showed neurosensory detachment and macular edema. This case report warrants the importance of ocular screening in a patient having systemic complications of DF.

Keywords: Central retinal vein occlusion, dengue fever, macular edema, neurological complications, retinal hemorrhages


How to cite this article:
Joshi RS, Wadekar PD. Bilateral retinal hemorrhages and macular edema in a patient with dengue fever associated with cerebral hemorrhage. Pan Am J Ophthalmol 2021;3:34

How to cite this URL:
Joshi RS, Wadekar PD. Bilateral retinal hemorrhages and macular edema in a patient with dengue fever associated with cerebral hemorrhage. Pan Am J Ophthalmol [serial online] 2021 [cited 2021 Dec 7];3:34. Available from: https://www.thepajo.org/text.asp?2021/3/1/34/329086




  Introduction Top


Dengue is one of the most common mosquito-borne disease-affecting humans. It is caused by a Flavivirus and spread by Aedes aegypti mosquitoes. It is highly prevalent in Southeast Asia, India, and American tropics.[1] The most common ocular symptom reported by patients having dengue fever (DF) is blurring of vision. However, this calls for a thorough evaluation of anterior and posterior segments. Although ocular manifestations are rare, they range from subconjunctival, vitreous, and retinal hemorrhages to uveitis, retinal vascular occlusion, optic neuritis, and macular edema. The precise pathophysiology of ophthalmic complications in dengue is not well understood. In addition, there is no specific treatment for ophthalmic manifestations of DF. However, DF manifestations are commonly reported in young adults with severe thrombocytopenia. Studies have shown that the involvement of ocular structures indicates the correction of thrombocytopenia.[2]

Systemic hemorrhagic complications are reported frequently in the form of menorrhagia, gum bleeding epistaxis, and hematuria. Isolated cases of retinal hemorrhages and macular edema have been reported in the literature. Herein, we report a case of bilateral retinal hemorrhages with macular edema in a patient with neurological complications due to DF.


  Case Report Top


A 17-year-old female presented with sudden painless loss of vision in her both eyes for 2 days associated with redness of eyes. She was diagnosed having DF based on detected dengue immunoglobulin M (IgM) in her blood sample. She was previously admitted to another clinic with symptoms of fever, headache, vomiting, bleeding from gums, and altered sensorium. Her ocular symptoms started on day 11 of DF when she was discharged from the hospital. There was no history of floaters, photopsia, and pain on ocular movements. The patient did not have any ocular complaints, and her vision was satisfactory before the development of loss of vision in her eyes.

On investigation, her peripheral smear was found to be normal, except for platelet count, which was 70,000/μl (normal 150,000–450,000/μl). Her count dropped to 10,000/μl on the 3rd day of admission. Details of the blood count are shown in [Table 1]. A diagnosis of DF was based on positive dengue non-structural protein antigen and dengue-specific immunoglobulin. Her liver and renal function tests and chest radiograph were normal. Her sickling test was negative. Computerized tomography of the head showed cerebral bleeding. Accordingly, she was started on supportive therapy, and platelet transfusion was given when she was admitted for fever, following which her platelet count showed improvement.
Table 1: Blood counts during the hospital stay

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On ophthalmic evaluation, visual acuity of both eyes was 1/60 on Snellen's chart. Anterior segment examination showed subconjunctival hemorrhage in both eyes with normal pupil size pupil that reacted to light. The remaining anterior segment examination was normal. Intraocular pressure by applanation tonometer in both eyes was 16 mmHg.

Dilated fundus examination of the right eye showed clear ocular media with preretinal hemorrhage in front of the disc due to which details of the optic disc could not be noted. Retinal vessels near the disc were obscured by preretinal hemorrhages. Peripheral vessels were found to be narrow, along with the presence of sheathing. At places, dark hemorrhages were present, which is suggestive of intraretinal hemorrhages [Figure 1].
Figure 1: Right eye fundus photograph showing intraretinal hemorrhage (red arrow) and sheathing of vessels by white arrow

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Left eye retinal examination showed intraretinal and preretinal hemorrhage in optic disc, which was faintly seen with disc hemorrhage. Macular hemorrhage was seen superior nasally to the fovea. Periphery of the retina showed sheathed vessels [Figure 2]. In both the eyes, foveal reflex was absent and macular edema was present. The right eye macula showed macular hemorrhage.
Figure 2: Left eye fundus photograph showing intraretinal hemorrhage (red arrow) and sheathing of vessels by white arrow

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Optical coherence tomography (OCT) line scans through the fovea of the right eye showed hyper-reflective inner layers with optical shadow, suggestive of intraretinal hemorrhage (white arrow) with intraretinal cystoid spaces. This indicates macular edema. Neurosensory detachment was also observed, as depicted by yellow arrow [Figure 3]. OCT lines scan obtained through the fovea of the left eye revealed marked retinal thickening and areas of low intraretinal thickening [Figure 4]. This is consistent with cystic fluid accumulation, especially in the outer plexiform layer of the retina.
Figure 3: Right eye optical coherence tomography line scans showing hyper-reflective inner layers with optical shadow suggestive of intraretinal hemorrhage (yellow arrow) with intraretinal cystoids spaces and neurosensory detachment (red arrow)

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Figure 4: Left eye Optical coherence tomography (OCT) line scans showing hyper-reflective inner layers with optical shadow suggestive of intra-retinal hemorrhage (Yellow arrow) with intra retinal cystoid spaces and neuro sensory detachment (Red arrow)

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In view of the severity of her visual symptoms and findings of retinal hemorrhages and macular edema, it was decided to administer steroid treatment to the patient. Intravenous methylprednisolone (1 g/day) was immediately started for 3 days, followed by oral prednisolone (1 mg/kg body weight) in tapering doses for 21 days. Her macular edema resolved in 4 weeks, and retinal hemorrhages resolved in 4 months. Her visual acuity improved to 20/30 on the last visit. Dilated retinal examination showed the absence of foveal reflex and sheathed peripheral vessels.


  Discussion Top


DF is common in tropical countries. Systemic complications related to DF are well known. However, DF-related ocular complications are rare and its manifestation varies from patient to patient. The posterior segment manifestations include vitritis, retinal and macular hemorrhages, retinal exudates, foveolitis, and branch retinal occlusion.[3],[4],[5],[6],[7],[8] The pathogenesis of ophthalmic manifestations is indicative of both host and immunologic factors.[5],[9] Several pathophysiologic mechanisms are involved in the causation of ophthalmic manifestations. These include thrombocytopenia, immune complex-mediated increased vascular permeability, occlusive events in retinal vessels, and inflammation.[5],[9]

The most common ocular symptom associated with maculopathy is blurring of vision. About 51.2% of patients with dengue-related maculopathy have blurring of vision.[10] Visual acuity is worst when the patient has dengue maculopathy along with foveolitis.[6] Su et al. have shown that dengue-related maculopathy reduces vision worse than LogMar 0.15.[11] Teoh et al. have shown that patients with cystoid macular edema had poorer visual acuity and degree of visual loss and prognosis correlated with the amount of macular edema.[12] Based on retinal examination, our patient was diagnosed with dengue maculopathy and macular hemorrhages in both eyes. OCT imaging of both eyes showed macular edema and neurosensory detachment. Neurosensory detachment can present with visual acuity from 20/20 to counting fingers.[1],[11] However, the present case had macular edema, leading to gross reduction in visual acuity. Kan et al. reported a case of bilateral DF maculopathy with foveolitis in postpartum females. The best-corrected visual acuity in the right eye was 6/24 and 1/60 in the left eye. Retinal examination did not reveal any vitreous or retinal hemorrhages. OCT imaging did not show macular edema in their case.[6]

Gross vision loss in our patient was due to cystoid macular edema that was also associated with neurosensory detachment also. Dengue-related maculopathy is associated with macular edema.[1],[12] However, dengue-related macular edema without retinal hemorrhages has also been reported.[13],[14]

In view of immune-mediated pathophysiology of the disease and the severity of visual symptoms in our case, intravenous methylprednisolone was started. Intravenous methylprednisolone has been reported to improve visual symptoms in various studies.[9],[15],[16],[17] Studies have shown improvement in visual symptoms and signs after platelet transfusion.[2],[13] In their case of permanent visual loss due to retinal capillary occlusion because of DF, Siqueira et al. gave their patient oral antiplatelet for 20 days.[3] However, in our case, despite platelet transfusion, there was no improvement in signs and symptoms. Therefore, intravenous methylprednisolone was given. Another reason could be the development of vasculitis, which is due to deposition of immune complexes on the walls of vessels. Dengue viremia stimulates antibody formation, which leads to the deposition of antigen–antibody complex on the vessel walls. This leads to inflammation of retinal vessels.[9] This was evident in our case as peripheral vessels showed sheathing of vessel walls. Improvement in visual acuity and resolution of macular edema after injection of methylprednisolone supports this theory of the underlying immunological process involved in the causation of the disease.

Few researchers have shown the role of immunoglobulin in patients having dengue maculopathy and foveolitis.[6],[10] Bacsal and Kan et al. have shown improvement in visual acuity in patients having dengue maculopathy after administration of immunoglobulin.[6],[10] In our case, satisfactory improvement of vision was seen after administration of methylprednisolone; therefore, immunoglobulin was not considered.

DF can affect many organs including the central nervous system. In our case, the patient had cerebral hemorrhage due to which the patient had altered sensorium. The patient complained of diminished vision once she recovered from the fever and systemic complications.

This case is being reported because, to the best of our knowledge, cerebral hemorrhage with bilateral retinal hemorrhages and macular edema has not been described previously in the literature.

This case report warrants the importance of ocular screening in a patient having systemic complications of DF.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name 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.
Chan DP, Teoh SC, Tan CS, Nah GK, Rajagopalan R, Prabhakaragupta MK, et al. Ophthalmic complications of dengue. Emerg Infect Dis 2006;12:285-9.  Back to cited text no. 1
    
2.
Chlebicki MP, Ang B, Barkham T, Laude A. Retinal hemorrhages in 4 patients with dengue fever. Emerg Infect Dis 2005;11:770-2.  Back to cited text no. 2
    
3.
Siqueira RC, Vitral NP, Campos WR, Oréfice F, de Moraes Figueiredo LT. Ocular manifestations in dengue fever. Ocul Immunol Inflamm 2004;12:323-7.  Back to cited text no. 3
    
4.
Lim WK, Mathur R, Koh A, Yeoh R, Chee SP. Ocular manifestations of dengue fever. Ophthalmology 2004;111:2057-64.  Back to cited text no. 4
    
5.
Kanungo S, Shukla D, Kim R. Branch retinal artery occlusion secondary to dengue fever. Indian J Ophthalmol 2008;56:73-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Kan KW, Sylves P, Nik-Ahmad-Zuky NL, Shatriah I. Dengue maculopathy with foveolitis in a postpartum female. Cureus 2017;9:e1942.  Back to cited text no. 6
    
7.
Gupta P, Jain C, Aggarwal A, Gupta SC. Dengue fever presenting with macular hemorrhages. Retin Cases Brief Rep 2011;5:213-8.  Back to cited text no. 7
    
8.
Velaitham P, Vijayasingham N. Central retinal vein occlusion concomitant with dengue fever. Int J Retina Vitreous 2016;2:1-4.  Back to cited text no. 8
    
9.
Chang PE, Cheng CL, Asok K, Fong KY, Chee SP, Tan CK. Visual disturbances in dengue fever: An answer at last? Singapore Med J 2007;48:e71-3.  Back to cited text no. 9
    
10.
Bacsal KE, Chee SP, Cheng CL, Flores JV. Dengue-associated maculopathy. Arch Ophthalmol 2007;125:501-10.  Back to cited text no. 10
    
11.
Su DH, Bacsal K, Chee SP, Flores JV, Lim WK, Cheng BC, et al. Prevalence of dengue maculopathy in patients hospitalized for dengue fever. Ophthalmology 2007;114:1743-7.  Back to cited text no. 11
    
12.
Teoh SC, Chee CK, Laude A, Goh KY, Barkham T, Ang BS, et al. Optical coherence tomography patterns as predictors of visual outcome in dengue-related maculopathy. Retina 2010;30:390-8.  Back to cited text no. 12
    
13.
Tan CS, Teoh SC, Chan DP, Wong IB, Lim TH. Dengue retinopathy manifesting with bilateral vasculitis and macular oedema. Eye (Lond) 2007;21:875-7.  Back to cited text no. 13
    
14.
Quek DT, Barkham T, Teoh SC. Recurrent bilateral dengue maculopathy following sequential infections with two serotypes of dengue virus. Eye (Lond) 2009;23:1471-2.  Back to cited text no. 14
    
15.
Yamamoto Y, Takasaki T, Yamada K, Kimura M, Washizaki K, Yoshikawa K, et al. Acute disseminated encephalomyelitis following dengue fever. J Infect Chemother 2002;8:175-7.  Back to cited text no. 15
    
16.
Preechawat P, Poonyathalang A. Bilateral optic neuritis after dengue viral infection. J Neuroophthalmol 2005;25:51-2.  Back to cited text no. 16
    
17.
Beral L, Merle H, David T. Ocular complications of dengue fever. Ophthalmology 2008;115:1100-1.  Back to cited text no. 17
    


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