CHICKEN POX ASSOCIATED BILATERAL RETINAL VASCULITIS IN AN IMMUNOCOMPETENT YOUNG MALE ; AN UNUSUAL CASE REPORT Affiliation

Chicken pox is considered as benign infectious disease with variable ocular manifestations. We report a case of bilateral retinal vasculitis following chicken pox in a healthy 17-year-old male. The retinal manifestation is stabilized by treatment with oral acyclovir in combination with systemic steroids.


INTRODUCTION
Ocular involvement a er primary Varicella Zoster Virus ( VZV) infec on or chickenpox is rare and may involve any part of the eye from the conjunc va to the op c nerve.Reported re nal vascular involvement in VZV infec on include vasculi s, transient re nal arterioli s, occlusive vasculopathy and recurrent mul ple branch re nal artery 1-3 occlusions.We describe herein the case of bilateral ischaemic re nal vasculi s associated with chickenpox .

CASE DESCRIPTION
A healthy 17-year-old student from Begulsarai, India presented with a 2 week history of chickenpox in the out pa ent department .Ten days a er the onset of cutaneous vesicular erup on, he experienced painless blurring of vision in his right eye.At the me of presenta on, 3 days a er the onset of symptoms, visual acuity in his right eye was 20/80.Examina on of the anterior segment was unremarkable .Fundus examina on revealed areas of prere nal and intra-re nal haemorrhages in the temporal and infero-temporal quadrant along with peri-venous sheathing and exuda on [Figure 1   Visual acuity in his le eye was 20/20 with unremarkable anterior segment examina on.Fundus evalua on of le eye revealed few areas of vascular sheathing in infero-temporal quadrant [Figure 2 A ]. Fluorescein angiography of le eye revealed areas of peri-vascular leakage [Figure 2B].The typical signs and symptoms of chickenpox had already subsided, except crusted erup ons on his face, limbs and abdomen that remained at the me of our examina on [Figure 3A, Figure 3B].He had no other relevant past history sugges ve of immunocompromised status and had no high risk behaviours.Regarding his immunisa on statu, we were unable to elicit a definite immunisa on history but he had no personal or family history sugges ve of any serious illness in the past.Both serum an -VZV immunoglobulin M (5.88 Index Value) and immunoglobulin G (1689.0 mlu/ml) an bodies were elevated.VZV DNA was detected by polymerase chain reac on (PCR) from the vitreous cavity.

Case Report
Gurung RL Since the pa ent had not consulted any physician for his skin lesions and had not taken any an -viral medica on for his condi on; there were features of ac ve re nal involvement, a clinical diagnosis of chicken pox with re nal vasculi s was made and he was started on oral Acyclovir 800 mg five mes per day induc on phase for 2 weeks followed by maintenance phase 400 mg two mes per day for 6 weeks along with oral steroid 1 mg / kg / day.At 2 weeks follow up, there was improvement in his visual acuity with improving vasculi s.However, the pa ent did not immediately follow up and he came back a er 3 months with deteriora on.At 3 months, his visual acuity RE was 20/200 with significant vitri s.Fundus evalua on of RE revealed ac ve fibro-vascular ssue on the op c nerve head and along the vascular arcade with macular involvement.Rest of the anterior segment examina ons, intra-ocular pressure, gonioscopy were unremarkable.He was re-started on oral Acyclovir along with oral steroid.Prophylac c laser was done over the nonperfused areas to prevent further ischaemia.Two weeks a er re-star ng of medica on, the visual acuity RE improved to 20/125.There was significant improvement in vitri s and stabiliza on of fundus findings.

DISCUSSION
Chickenpox, caused by primary VZV infec on, is infrequently associated with ocular inflamma on and rarely with posterior segment inflamma on.There are very few case series and case reports regarding the ocular manifesta ons 4 of primary varicella infec on.Gargouri et al reported case series of five adults (seven eyes) with ocular involvement secondary to chickenpox.Anterior uvei s was the most frequently reported ocular manifesta on.What is unique about our case, is that the pa ent had bilateral re nal vasculi s without anterior segment involvement which stabilized a er the use of oral acyclovir.Although VZV is the most common causa ve agent of acute re nal necrosis (ARN) syndrome, this clinical en ty has been rarely described 1 following chickenpox infec on.Matsuomo et al reported case series of three pa ents with ARN following chicken pox.The clinical features in our case differed from ARN in the following points: (1) absence of anterior chamber and vitreous inflamma on, (2) absence of classical necro c re nal lesions.
There are only two case reports of re nal vasculi s associated with primary varicella infec on.Poonyathalang It is uncertain whether this resulted from an immunologic response or the infec ous process caused by VZV.No definite guideline for the management of such cases is available due to the limited number of cases reported.
Treatment with systemic steroids alone or combined with an viral agents has been described in previous case reports .Acyclovir has been used orally and intravenously in these 6 pa ents.Other an -virals used are gancyclovir, foscarnate.
As these lesions resolve with or without an -viral medica ons, the precise role of an -viral is not clear.It is also unclear whether Zoster vaccina ons prevent such clinical manifesta on .There have been reports of pa ents 7 developing Zoster ARN a er Zoster vaccine administra on.

CONCLUSION
We report an immunocompetent 17 year old young adult who presented with bilateral re nal vasculi s a er chickenpox.It is important to perform a detailed ocular examina on in pa ents with varicella infec on.Immediate recogni on and proper treatment with systemic an viral therapy may be essen al for the preven on of severe sequelae and good visual outcome.However, a generalized comment cannot be made based on our single case.A large series is required to provide the correct guidelines for therapy.
A]. Fluorescein angiogram of right eye revealed mul ple areas of patchy capillary dropouts, diffused vascular leakage and staining [Figure 1 B] .

2 et
al reported a case of unilateral ischaemic re nal vasculi s 3 in a healthy adult following chickenpox.YH Kuo et al reported a case of mild re nal vasculi s associated with primary chickenpox infec on.Both cases had unilateral presenta on unlike in our case which had bilateral involvement.Murdock et al had reported a case of bilateral re nal vasculi s in an adult with chickenpox with systemic vasuli s.In our pa ent, increased varicella zoster virus IgM tre showed the immunological evidence of recent primary varicella infec on which was further confirmed by posi ve PCR test of vitreous fluid .