Cytomegalovirus-Induced Optic Neuritis Through Cerebrospinal Fluid Viral Transmission in an Immunocompetent Patient: A Case Report
Cytomegalovirus-Induced Optic Neuritis Through Cerebrospinal Fluid Viral Transmission in an Immunocompetent Patient: A Case Report
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免疫功能正常患者中巨细胞病毒通过脑脊液病毒传播引起的视神经炎：病例报告
DOI：
10.1097/wno.0000000000001834
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发表时间：
2023
期刊：
影响因子：
--
通讯作者：
PhD
中科院分区：
文献类型：
--
作者：
Takahashi;Shizuka MD;PhD; Hashida;Noriyasu MD;PhD; Maruyama;Kazuichi MD;PhD; Omura;Rina MD; Sakurai;Rei MD; Morimoto;Takeshi MD;PhD; Nishida;Kohji MD;PhD
巨细胞病毒（CMV）感染眼睛的临床表现，如角膜内皮炎，虹膜睫状体炎，视网膜炎，1和乳头炎，2，不仅在免疫功能低下的宿主中，也在免疫功能正常的宿主中观察到。在免疫正常的宿主中，感染通常是双眼的，但从一只眼睛到另一只眼睛的传播途径尚不清楚。我们报告了一例免疫功能正常的患者的左眼视神经炎（OS）由病毒感染的脑脊液（CSF）传播引起的巨细胞病毒视网膜炎右眼（OD）。一名63岁的男子自诉视力模糊。一年前有白内障手术史，8个月前巩膜内固定人工晶状体，2个月前因视网膜脱离进行了第二次玻璃体切除术。最佳矫正视力（BCVA）为20/63 OD， 20/25 OS。眼内压（IOP）为23 mm Hg OD， 14 mm Hg OS。裂隙灯检查，外径有色素、棘状角化沉淀和2+前房细胞。眼底镜检查显示白色的绒毛膜视网膜斑点从视网膜赤道向外周分散，术后鼻上视网膜视网膜脱离形成疤痕（图1A）。聚合酶链反应（PCR）检测到房水中CMV共为6.06× 104拷贝/mL，未检测到其他感染因子。实验室检查：白细胞微增高（9.57× 103/mL）， c反应蛋白阴性，HbA1c 6.7%，中性粒细胞55%，淋巴细胞36.4%，单核细胞5.2%，嗜酸性粒细胞2.8%，嗜碱性粒细胞0.6%，CMV抗原阴性，其他未见异常。CD4 T淋巴细胞不可用。弓形虫IgM、IgG、梅毒、人t淋巴病毒1型、HIV血清学结果均为阴性。从胸部到骨盆的计算机断层扫描和脑部MRI包括眼眶视图未见明显发现。他接受了免疫专家的评估，没有发现免疫缺陷。经PCR检测阳性，诊断为巨细胞病毒性视网膜炎，给予口服缬更昔洛韦900 mg，每日2次。然而，由于严重腹泻，它被减少到450毫克，然而导致成功缓解。治疗后眼底照片可见萎缩的白斑（图1B）；然而，视界视力没有改善。随后，他在巨细胞病毒性视网膜炎（伴有OD）缓解7周后主诉视力模糊。BCVA恶化至20/125 OD和20/320 OS。眼压为19 mm Hg OD， 14 mm Hg OS。裂隙灯检查显示双眼前房无炎症。眼底镜检查显示OS视盘肿胀。光学相干断层扫描显示均匀的中央凹下视网膜下积液（SRF）。1 c)。脂肪饱和t2加权MRI显示左眶神经纵向强化病变，提示视神经炎（图2A）。临界融合频率（CFF） OD为30 ~ 30 Hz， OS为7 ~ 7 Hz。动力学验光显示OS水平偏视较低（图2C）。对房水CMV进行PCR检测，OD值为1.30× 104 copies/mL， OS值为阴性。脑脊液PCR检测CMV阳性。血CMV抗原阴性。因此，他在OS中被诊断为病毒性视神经炎，并静脉注射更昔洛韦3周和2个疗程的3天高剂量皮质类固醇（1g甲基强的松龙），通过PCR检测导致CSF CMV阴性，SRF快速消退（图1D）。BCVA改善至20/40 OD， 20/63 OS，视野损害部分恢复，视力改善。
Clinical findings, such as corneal endothelitis, iridocyclitis, retinitis, 1 and papillitis, 2 are observed in the cytomegalovirus (CMV)-infected eyes not only in immunocompromised hosts but also in immunocompetent hosts. Infection is often binocular in immunocompetent hosts, but the pathway of propagation from one eye to the other is unclear. We report the case of optic neuritis in the left eye (OS) induced by virus-infected cerebrospinal fluid (CSF) transmission from the CMV retinitis–bearing right eye (OD) in an immunocompetent patient. A 63-year-old man complained of blurred vision in the OD. He had a history of cataract surgery of the OD a year ago, intrascleral fixation of an intraocular lens 8 months ago, and a second vitrectomy for retinal detachment 2 months ago. His best-corrected visual acuity (BCVA) was 20/63 OD and 20/25 OS. His intraocular pressure (IOP) was 23 mm Hg OD and 14 mm Hg OS. On slit-lamp examination, the OD had pigmented, spiny keratic precipitates and 2+ anterior chamber cells. Fundoscopy revealed white chorioretinal spots scattered from the equator of the retina to the periphery and postoperative scarring due to the retinal detachment in the superior nasal retina (Fig. 1A). A total of 6.06× 104 copies/mL CMV in the aqueous humor was detected by polymerase chain reaction (PCR) analysis, whereas no other infectious agents were detected. The laboratory examination showed slightly increased white blood cells (9.57× 103/mL), negative C-reactive protein, 6.7% HbA1c, neutrophils 55%, lymphocytes 36.4%, monocytes 5.2%, eosinophils 2.8%, basophils 0.6%, negative CMV antigen, and no other abnormalities. The CD4 T lymphocyte was not available. Toxoplasma IgM and IgG, syphilis, human T-lymphotropic virus 1, and HIV serology results were negative. Computed tomographic scans from the chest to the pelvis and brain MRI including orbital views showed no significant findings. He underwent evaluation with an immunology specialist, and no immunodeficiency was identified. Based on the positive PCR testing, CMV retinitis was diagnosed and we administered oral valganciclovir, 900 mg twice daily. However, it was decreased to 450 mg due to severe diarrhea, nevertheless leading to successful remission. The atrophied white spots were observed in the fundus photograph after treatment (Fig. 1B); however, visual acuity in the OD did not improve. Subsequently, he complained of left blurred vision 7 weeks after the remission of the CMV retinitis-bearing OD. His BCVA worsened to 20/125 OD and 20/320 OS. The IOP was 19 mm Hg OD and 14 mm Hg OS. Slit-lamp examination revealed no inflammation in the anterior chamber of either eye. Fundoscopy revealed optic disc swelling in the OS. Optical coherence tomography showed even subfoveal subretinal fluids (SRF)(Fig. 1C). Fat-saturated T2-weighted MRI showed a longitudinal enhancing lesion of the left orbital nerve, suggesting optic neuritis (Fig. 2A). The critical fusion frequency (CFF) was 30-30 Hz OD but only 7-7 Hz OS. Kinetic perimetry showed lower horizontal hemianopia in the OS (Fig. 2C). PCR of the aqueous humor for CMV revealed 1.30× 104 copies/mL in the OD and was negative in the OS. PCR of CSF was positive for CMV. Blood CMV antigen was negative. Therefore, he was diagnosed with viral optic neuritis in the OS and treated with intravenous ganciclovir for 3 weeks and 2 courses of 3-day high-dose corticosteroids (1 g methylprednisolone), leading to negative CSF CMV by PCR and rapid resolving of SRF (Fig. 1D). His BCVA improved to 20/40 OD and 20/63 OS, and the visual field impairment partially recovered, accompanied by the improved …