Optic neuritis as the Initial Manifestation of varicella-zoster virus–induced progressive retinal necrosis and encephalitis in a patient with AIDS

Abstract

Introduction:
Optic neuritis (ON) is increasingly reported in patients infected with the human immunodeficiency virus (HIV). In rare cases, it may reveal an HIV infection caused by an opportunistic infection. We report the case of a patient in whom varicella-zoster virus–related optic neuritis was the initial manifestation of HIV infection.
Case Presentation:
A 32-year-old man presented with progressive left-sided visual loss evolving over two weeks. The initial ophthalmologic examination was unremarkable. Brain MRI (magnetic resonance imaging) showed thickening and hyperintensity of the left optic nerve, consistent with retrobulbar optic neuritis (RBON). The diagnosis of retrobulbar optic neuritis related to a neuromyelitis optical spectrum disorder with anti–aquaporin-4 antibodies was considered. Corticosteroid bolus was prescribed as well as sessions of plasmapheresis with no significant improvement. The evolution was characterized by the occurrence of a febrile confusion, cutaneous lesions consistent with herpes zoster (involving the V1 dermatome, palms, back, and buttocks), and right-sided ptosis. Ophthalmologic examination
revealed right oculomotor palsy and left-sided retinal necrosis. Given this clinical worsening, HIV serology was positive with a plasma viral load at 16,400 copies/mL and the initial CD4 count was 16.4 cells/mm3. Repeated brain MRI demonstrated pachymeningitis and a right cortical encephalitic lesion. VZV PCR was positive in both cerebrospinal fluid and aqueous humor. Intravenous acyclovir was prescribed for 21 days with intravitreal injection of ganciclovir, followed by oral valacyclovir. The subsequent onset of contralateral retinitis required resumption of intravenous acyclovir. The patient remains on secondary prophylaxis with stable right retinal lesions.

Conclusion:
This case highlights the importance of investigating HIV and VZV infections in the context of optic
neuropathy.