1. Varicella-zoster necrotising retinitis with panuveitis following uncomplicated chickenpox in a seemingly immune competent child
S Chamney1, J Yu1, S Hughes2, N Jones1, J Ashworth 1.
1. Manchester Royal Eye Hospital, 2. Department of Immunology, Royal Manchester Children's Hospital.
History:
A 4 year old girl presented with a 2 week history of a red sore left eye and decreased vision (Right eye 0.0 and Left eye 0.2 Logmar) for 4 days. She had chickenpox 4 weeks earlier but was otherwise well. She had a past medical history of eczema. She was born full term, normal delivery . Her immunisations were up to date. Her mother was Japanese, her father British. She had been in Japan when she developed the chicken pox.
Optos images of Left fundus at presentation showing papillitis, peripheral vasculitis and retinitis
Clinical findings:
She had left panuveitis with 3+ of cells in the anterior chamber with fine KPs, substantial vitritis, papillitis and retinal venous tortuosity. In addition here was a zone of peripheral vasculitis and white retinitis temporally. Her intra-ocular pressure was 18mmHfg in the right eye and 7mmHg in the left eye (I-care). The right eye was normal. Over 4 days her visual acuity in the left eye dropped to 0.98 Logmar)
Management:
The child was admitted and received 10 days of IV aciclovoir 10mg/kg, together with topical steroid. She also underwent anterior chamber tap (combined with intravitreal foscarnet injection), which was PCR positive for Varicella zoster viral DNA, consistent with active infection. Her blood VZV PCR was also positive . Six days after the initiation of aciclovir she was commenced on oral prednisolone (20mg) .
Optos images of Left fundus 8 weeks following treatment with resolution of the disc swelling and peripheral changes
Results/Outcome:
Her uveitis and retinitis gradually improved. Her vision returned to 0.08 Logmar in the left eye. After completing a reducing course of topical and oral steroids she continues to be treated with a prophylactic dose of oral aciclovoir (400mg BD). Immunology investigation revealed reduced CD4 count of 371 x106/l (reference range ) (HIV serology negative). Her CD4 count has now return to normal (1026 x106/l). Her other immunology investigations have come back as normal including CD4 proliferation testing. It is now felt that the low CD4 count may have been caused by the primary VZV infection
Conclusion:
Necrotising viral retinitis is very rare in immune competent children following chickenpox. This case highlights the importance of careful fundal exam in childhood uveitis, and a multidisciplinary approach to management.
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