Bilateral panophthalmitis in dengue fever

Abstract

We report the case of a 25-year-old male patient who presented with bilateral panophthalmitis as the initial ocular manifestation of dengue fever. The diagnosis was a little confusing as he initially presented with features suggestive of retrobulbar hemorrhage secondary to his very low platelet count, which is a common feature of dengue fever. Ophthalmic complications are usually seen in young adults who often present at the nadir of thrombocytopenia. Ocular findings may include anterior uveitis, vitritis, retinal hemorrhages, retinal vascular sheathing, yellow subretinal dots, retinal pigment epithelium (RPE) mottling, foveolitis that is clinically seen as a round subretinal yellowish lesion at the fovea, retinochoroiditis, choroidal effusion, optic disc swelling, optic neuritis, neuroretinitis, and oculomotor nerve palsy. [1] There is only one reported case of unilateral endogenous panophthalmitis due to dengue fever. Hence, clinicians and ophthalmologists have to be aware of this vision-threatening complication of dengue for early recognition and prompt treatment to save the vision of these young patients and prevent morbidity.

Keywords: Dengue fever, endogenous panophthalmitis, morbidity, thrombocytopenia

How to cite this article:
Sriram S, Kavalakatt JA, Pereira Ad, Murty S. Bilateral panophthalmitis in dengue fever. Ann Trop Med Public Health 2015;8:217-8
How to cite this URL:
Sriram S, Kavalakatt JA, Pereira Ad, Murty S. Bilateral panophthalmitis in dengue fever. Ann Trop Med Public Health [serial online] 2015 [cited 2017 Nov 14];8:217-8. Available from: https://www.atmph.org/text.asp?2015/8/5/217/159837
Introduction

Dengue fever, a mosquito-borne disease commonly found in the tropics, is the most prevalent form of Flavivirus infection in humans. It is transmitted to humans by the bite of an infected female Aedes aegypti mosquito and characterized by an acute onset of fever associated with symptoms of malaise, sore throat, rhinitis, cough, headache, muscle ache, retro-orbital pain, joint pain, abdominal discomfort, rash, and bleeding diathesis. [2] The illness is usually self-limiting with minimal systemic sequelae but it may require prolonged convalescence that lasts several weeks. Since the early 2000s, there has been an increasing number of reports describing a myriad of ocular signs and symptoms associated with dengue fever, the precise pathophysiologic mechanism of which is not well-understood. [3] Many studies have eluded it to the possibility of an immune-mediated process as a likely mechanism. [4] Panophthalmitis is an uncommon but sight-threatening intraocular infection, often associated with poor visual prognosis. [5] The incidence of dengue-associated maculopathy and neuropathy among the myriad of dengue-associated ophthalmic complications is minimal, which leads to a general consensus that dengue is associated with generally favorable visual prognosis. In the light of this background, we report a case of bilateral panophthalmitis secondary to dengue fever.

Case Report

A 25-year-old man presented with a 1-week history of fever and 3 days of proptosis with acute pain in both his eyes and bleeding of his left eye [Figure 1]. He was earlier admitted for the same in another hospital and was treated with intravenous (IV) antibiotics and platelet transfusions. His platelet count was 10,000/μL. He also had three episodes of epistaxis and melena during this time.

Figure 1: Bilateral proptosis with right eye silvery white cornea and bleeding of the left eye at presentation

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His initial clinical evaluation showed no perception of light and severe tender proptosis OU. His right eye showed conjunctival chemosis with silvery white cornea. His left eye was not visualized owing to dry blood clot in the interpalpebral area. A clinical diagnosis of severe retrobulbar hemorrhage was done. Bilateral canthotomy with cantholysis was also done. Computed tomography (CT) orbit showed bilateral periorbital soft tissue thickening with preseptal fat stranding, suggestive of orbital inflammation.

The next day, after successful clot removal following platelet transfusion, bilateral horizontally oval cloudy cornea with ring abscess at the limbus with complete hypopyon and hyphema was noted. There was complete external ophthalmoplegia OU. The left eye, then, became extremely soft and deformed, suggestive of globe perforation. B-scan showed bilateral retinochoroidal complex thickening with vitreous exudates. Eye swab showed gram-positive cocci, scanty pus cells, and no growth on culture. Blood and urine cultures were negative for growth. Serology was positive for immunoglobulin G (IgG) and immunoglobulin M (IgM) for dengue.

The patient was given IV ceftriaxone, vancomycin, mannitol, dexamethasone, systemic acetazolamide, topical moxifloxacin, fortified vancomycin, fortified ceftazidime, brimonidine, travoprost, dorzolamide, and platelet transfusions. Following the treatment of proptosis, inflammation and intraocular pressure (IOP) decreased and platelet count became normal. Both the eyes eventually became phthisical.

Discussion

Panophthalmitis is a severe involvement of the anterior and the posterior segments of the eye, presenting with marked lid edema, proptosis, limitation of ocular movements, and high IOP. The common symptoms include ocular pain, blurring of vision, and ocular discharge. During the later stages of infection, the patients may develop severe inflammation with chemosis, proptosis, and hypopyon that can lead to blindness. [6] Eventually, it destroys the globe and invades the orbit, resulting in blindness, phthisis, or enucleation. Since this disease occurs secondary to the hematogenous spread of microorganisms to the eye from a site of infection in the body, any disease process that produces septicemia can lead to the development of endophthalmitis. The pathogenesis of panophthalmitis in dengue is not known. It could be part of immunologic and inflammatory response to dengue virus infection. The fact that the condition developed at the nadir in the platelet count could be related to dengue being the severest at this point. It is postulated that the microorganisms after crossing the blood ocular barrier enter the uveal tract or retinal circulation as scattered organisms or in a bolus, and lodge in small capillaries. They establish a septic focus that can develop in the retina, prior to breaking into the vitreous. The infectious embolus is usually in proximity to the retinal vessels. If a large septic embolus passes through the central retinal artery and disseminates throughout the retina, retinal necrosis and ischemia may occur, allowing the microorganism to quickly invade the vitreous and further into the anterior segment.

Panophthalmitis, though rare in dengue, is vision-threatening. Hence, a systematic ophthalmic examination and intervention in dengue patients with ocular symptoms is mandatory. Ophthalmologists and physicians should be aware and vigilant toward patients with dengue-related ophthalmic complaints, as the patients may develop life-threatening panophthalmitis. To the best of our knowledge, till date, only one case of dengue with unilateral panophthalmitis has been reported. [7] A heightened awareness of dengue-related ophthalmic complications among the clinicians involved in the care of patients with dengue would facilitate prompt referral for ophthalmologic assessment and management.

References
1.
Lim WK, Mathur R, Koh A, Yeoh R, Chee SP. Ocular manifestations of dengue fever. Ophthalmology 2004;111:2057-64.
2.
World Health Organization. Dengue and dengue hemorrhagic fever-Fact sheet. 2009. Available from: http://www.who.int/csr/disease/dengue/en. [Last accessed on 2011 May 19].
3.
Haritoglou C, Dotse SD, Rudolph G, Stephan CM, Thurau SR, Klauss V. A tourist with dengue fever and visual loss. Lancet 2002;360:1070.
4.
Bacsal KE, Chee SP, Cheng CL, Flores JV. Dengue-associated maculopathy. Arch Ophthalmol 2007;125:501-10.
5.
Jackson TL, Eykyn SJ, Graham EM, Stanford MR. Endogenous bacterial endophthalmitis: A 17-year prospective series and review of 267 reported cases. Surv Ophthalmol 2003;48:403-23.
6.
Okada AA, Johnson RP, Liles WC, D′Amico DJ, Baker AS. Endogenous bacterial endophthalmitis. Report of a 10-year retrospective study. Ophthalmology 1994;101:832-8.
7.
Saranappa SB, Sowbhagya HN. Panophthalmitis in dengue fever. Indian Pediatr 2012;49:760.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.159837

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