Paracentral acute middle maculopathy following SARS-CoV-2 infection: the D-dimer hypothesis.
Paracentral acute middle maculopathy following SARS-CoV-2 infection: the D-dimer hypothesis.
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DOI：
10.1136/bcr-2021-242043
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发表时间：
2021-03-04
期刊：
影响因子：
0.9
通讯作者：
Kelgaonkar A
中科院分区：
文献类型：
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作者：
Padhy SK;Dcruz RP;Kelgaonkar A
我们在此报告一个19岁的女孩在感染SARS-CoV-2后出现双侧急性暗点的病例，原因是中心旁急性中黄斑病变（PAMM）。她在两周前通过逆转录PCR检测和放射学检查被检测为SARS-CoV-2感染阳性。她的医疗报告显示D-二聚体水平升高（1.23 μg/mL），治疗医生开始静脉注射类固醇和依诺肝素。她的右眼（RE）和左眼（LE）视力分别为20/40，N6和20/125，N6。眼底扩张评价显示沿着血管弓存在棉絮样斑点沿着双侧黄斑存在轻微白色病变（[图1A，B）。光学相干断层扫描（OCT）显示，内、外丛状层（IPL、OPL）存在局灶性超反射变化，伴内侧核层（INL）体积减少，与PAMM特征一致（图1C、D）。4周后复查时，她的视力在RE中改善至20/20，在LE中改善至20/25，重复D-二聚体水平正常。OCT显示INL变薄，IPL和OPL沿着不规则，以及棉絮斑点的分辨率（图2A-D）。Sarraf等人1首先将PAMM描述为OPL和INL水平处增厚的超反射带的谱域OCT表现。2 PAMM归因于中间和深部毛细血管丛缺血的急性期，这可能预示着潜在的继发性疾病如视网膜血管疾病的存在。D-二聚体通常在2019冠状病毒病（COVID-19）患者中升高，是一种纤维蛋白降解产物，在血栓形成事件中增加，表明纤维蛋白溶解。3 D-二聚体值升高，导致继发于全身炎症反应综合征的凝血级联激活，与此类患者的疾病严重程度和高死亡率相关。4-6 Virgo和Mohamed 7有趣地报告了SARS-CoV-2感染后的PAMM和急性黄斑神经视网膜病变的两例病例，可能属于“与SARS-CoV-2感染暂时相关的儿科炎症性多系统综合征”。8-10我们推测，视网膜毛细血管丛缺血导致PAMM可能是继发于血栓形成的环境，这是翻译的形式提高血液D-二聚体水平。对出现PAMM的COVID-19患者进行常规眼底检查和D-二聚体测定非常重要，因为这些患者必须立即抗凝。11 12假设，在得出有意义的结论之前，COVID-19患者中D-二聚体水平与PAMM的关系需要进一步关注。
We herein report a case of bilateral acute-onset scotoma following SARS-CoV-2 infection in a 19-year-old girl attributed to the presence of paracentral acute middle maculopathy (PAMM). She was tested positive for SARS-CoV-2 infection 2 weeks prior by reverse transcription PCR testing and radiologically. Her medical reports revealed a raised D-dimer levels (1.23 μg/mL), for which she was started on intravenous steroids and enoxaparin by the treating physician. Her presenting visual acuity was 20/40, N6 and 20/125, N6 in the right (RE) left eye (LE), respectively. Dilated fundus evaluation exhibited the presence of cotton wool spots along the vascular arcades along with subtle white lesions at macula bilaterally ([figure 1A, B). Optical coherence tomography (OCT) showed presence of focal hyperreflective change in the inner and outer plexiform layers (IPL, OPL) with inner nuclear layer (INL) volume loss parafoveally (figure 1C, D) features consistent with PAMM. On review after 4 weeks, her visual acuity improved to 20/20 in RE and 20/25 in LE, repeat D-dimer levels were normal. OCT showed thinning of INL with the irregularity of IPL and OPL along with the resolution of the cotton wool spots (figure 2A–D). Sarraf et al 1 first described PAMM to be a spectral-domain OCT manifestation of a thickened hyper-reflective band at the level of the OPL and INL. 2 PAMM has been attributed to the acute phase of ischaemia of intermediate and deep capillary plexuses which may herald presence of underlying secondary conditions like retinal vascular diseases. D-dimer, commonly elevated in coronavirus disease 2019 (COVID-19) patients, is a fibrin-degradation product which is increased in thrombotic events, indicating fibrinolysis. 3 Raised D-dimer values, lead to activation of coagulation cascade secondary to systemic inflammatory response syndrome, correlate to the disease severity and high mortality in such patients. 4–6 Virgo and Mohamed 7 interestingly reported two cases of PAMM and acute macular neuroretinopathy following SARS-CoV-2 infection, possibly under the umbrella of ‘paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 infection’. 8–10 We hypothesise that the retinal capillary plexus ischaemia leading to PAMM could be secondary to a thrombotic milieu which is translated in the form of raised blood D-dimer levels. Routine ocular fundus examination and ordering D-dimer assay in patients with COVID-19 presenting with PAMM is extremely crucial as prompt anticoagulation is mandated in these patients. 11 12 In supposition, the relationship of D-dimer levels with PAMM in patients with COVID-19 warrants further attention before a meaningful conclusion can be drawn.