History of present illness
A 49-year-old woman with type 2 diabetes mellitus (DM), hypertension, earlier fever of unknown origin, and hand numbness presented for her yearly diabetic eye examination. Her last dilated eye examination was 2 years earlier and had been unremarkable at that time. She reports stable vision with no ocular symptoms, including no flashes, floaters, pain, redness, or photophobia. She denies any family history of blindness or glaucoma.
Ocular examination findings
Visual acuity uncorrected was 20/25 in the right eye and 20/20 in the left eye. Intraocular pressures were 20 mm Hg in both eyes. External and anterior segment examinations were unremarkable except for bilateral trace nuclear sclerotic cataracts. Anterior chambers were quiet in both eyes, but dilated examination revealed 1+ anterior vitreous cell in the right eye with no vitreous haze. Both eyes had healthy optic discs, unremarkable macular areas, and a few dot-blot hemorrhages in two quadrants. The right eye had multiple flat, punched-out white lesions that were most prominent nasally and superiorly ( Fig. 38.1 ).
Imaging
Optical coherence tomography (OCT) ( Fig. 38.2 ) was obtained, which demonstrated a normal foveal contour without macular edema or disruption of the retinal layers in both eyes.
Questions to ask
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Does the patient have a history of systemic inflammatory disease, including sarcoidosis, systemic lupus erythematosus, rheumatoid arthritis, or other autoimmune disease that may be related to intraocular inflammatory disease? Does the patient have a history of symptoms consistent with the above diseases, including shortness of breath, cough, rashes, or joint pain and swelling?
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No
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Does the patient have a family history of systemic inflammatory disease?
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No
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Does the patient have a history of systemic infection, including tuberculosis (TB), syphilis, histoplasmosis, or toxoplasmosis? Does the patient have risks for exposure to these infections, including being from an endemic area (another country for TB, the Ohio and Mississippi River valleys for histoplasmosis), high-risk sexual behavior, or pet ownership? Does the patient have a history of symptoms consistent with these infections?
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No
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Does the patient have a history of viral infection, including herpes simplex virus 1 or 2, varicella zoster, or West Nile virus?
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Yes, the patient was hospitalized a year earlier with complications from West Nile virus, with positive serology testing at that time.
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Assessment
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This is a case of a 49-year-old woman with type 2 DM and history of hospitalization for West Nile fever presenting without ocular symptoms but with multiple chorioretinal lesions and vitreous cell in the right eye.
Differential diagnosis
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Multifocal choroiditis with panuveitis
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Ocular histoplasmosis syndrome
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Syphilitic uveitis
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Sarcoid uveitis
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TB uveitis
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Hypertensive retinopathy
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Diabetic retinopathy
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Ocular toxoplasmosis
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West Nile virus chorioretinitis
Working diagnosis
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Inactive West Nile virus chorioretinitis
Multimodal testing and results
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Fundus photographs
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Active disease has creamy white-yellow targetoid lesions 200 to 1000 μm in diameter in the midperiphery. Inactive disease has pigmented and atrophic punched-out chorioretinal scars. Lesions are typically clustered with curvilinear distribution along the course of nerve fibers ( Fig. 38.1 ). Mild vitritis is typical. Retinal hemorrhages and cotton wool spots are possible. Optic nerve involvement with optic neuritis or neuroretinitis are possible, as are retinal vasculitis and serous retinal detachment.
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OCT
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Our patient showed an unremarkable OCT. Lesions are typically outside the macula. OCT through lesions can show outer retinal disruption, including of the ellipsoid zone with possible hyperreflective outer retinal deposits.
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Fundus autofluorescence
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Hyperautofluorescent lesions in active disease and hypoautofluorescent lesions in inactive disease in the typical distribution ( Fig. 38.2 ).
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Fluorescein angiography (FA)
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FA showed typical distribution of inactive lesions with central hypofluorescence and a surrounding ring of staining, as well as areas of diabetes-related peripheral capillary nonperfusion in the right eye ( Fig. 38.3 ). The left showed microaneurysms consistent with nonproliferative diabetic retinopathy. Active lesions show early hypofluorescence and late staining. Choroidal neovascular membrane (CNVM) is possible at the site of lesions. Retinal vascular leakage is possible. Macular ischemia is a rare complication.
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