The eye in dengue fever, a rarely appreciated aspect of dengue expanded syndrome: a case report

Abstract

Background: Dengue fever is a mosquito-borne illness prevalent mainly in the tropics. It is feared for causing the dengue hemorrhagic spectrum of the disease leading to significant morbidity and mortality. Its rarer manifestations are categorized as the expanded dengue syndrome, and though being recognized, they are not fully appreciated and understood. The involvement of the eye in dengue fever is one such phenomenon.

Case presentation: A 27-year-old South-Asian woman presented on day 2 of dengue fever, without capillary leakage, for further management. Despite developing hepatitis, she had an otherwise uncomplicated progression of the illness because she did not develop capillary leakage. On day 8 of the illness, she had the lowest platelet count and developed bilateral blurred vision. Examination revealed that only gross movements were detected in the left eye, and the right eye had a visual acuity of 6/9. She was diagnosed with foveolitis in the right eye and central serous chorioretinopathy in the left eye, along with hemorrhages in both eyes. These were confirmed by funduscopy, fluorescein angiography, optical coherence tomography, and macular scans. She received systemic and intravitreal steroids and was assessed regularly. After 6 months of observation, her visual acuity was 6/6 in the right eye and 6/9 in the left eye, which remained the same thereafter.

Discussion: The exact mechanism of eye involvement in dengue viral infection is poorly understood. Multiple causes have been suspected and include viral factors, immune mediation, capillary leakage, stress, and hemorrhage. Eye involvement is classically seen at the lowest platelet count and when the count begins to rise. Though symptoms are nonpathognomonic, blurring of vision is the commonest complaint, but the range of presentation is extensive and variable. Ophthalmological assessment and funduscopy are very useful in addition to advanced assessments. There is no clear consensus on management; suggestions range from conservative care to aggressive steroid therapy with immune modulation and even ophthalmological intervention. Recovery can be full or partial with a variable time scale.

Conclusion: The extensive spectrum of possible visual symptoms should prompt the clinician to suspect any visual complaint as potential dengue eye involvement. Guided studies and screening are needed to better understand the true incidence of eye involvement in dengue fever.

Keywords: Central serous chorioretinopathy; Dengue; Dengue fever; Dengue maculopathy; Dengue retinopathy; Expanded dengue syndrome; Foveolitis.

Fig. 1

a and b are photo of both fundi. a is that of the right eye. The fovea (indicated by circle) appears relatively pale compared to that of what’s normal which is typical of dengue foveolitis. Additionally in the outer rim- temporally indicated by the arrow there are signs if resolving haemorrhages. b is that of the left eye. The faint circular light reflexion (indicated by the circle) centering around the fovea. This is the margin of retinal pigment epithelium (RPE) elevation. This demarcates the area of central serous chorioretinopathy (CSCR). Haemorrgahes are also observed. c and d are fourescein angiogras of both the right and left eye respectively. In d, the left eye the center of the macula and fovea is dark. There is a mild fluorecscnce of the fovea. The white halo clearly defines where the where the sub-retinal pigmental epithelium (RPE) fluid is present

Fig. 2

a and b Optical coherence tomography (OCT) of both eyes demonstrates retinal region involved. a Right eye. Increased thickness in the foveal region is demonstrated by the orange to pink hue. b Left eye. More marked involvement with a greater area affected is demonstrated by the pink and reddish hue centered on the fovea. Normal retinal thickness is < 320 μm within the green color spectrum, and the foveal thickness is usually 250 μm. c–f Macular scans concentrating on the region described in the OCT scans. c and d Horizontal cuts. e and f Vertical cuts. c and e Right eye. d and f Left eye. In both the horizontal (d) and vertical (f) cuts of the left eye, the foveal depression is lost and instead is elevated. The retinal pigmental epithelial  layer is lifted up, but not just at the fovea. Almost the whole macula is lifted up. The gap below the RPE is dark, suggesting the presence of fluid. This is a typical appearance of “central serous choroidoretinopathy.” In the right eye, depicted in c and e, elevation (second line from the bottom) is seen at the level of the fovea with a reflective material filling the space, suggestive of foveolitis

Fig. 3

a and b Macula scans of the right and left eyes, respectively. Marked improvement is seen in both eyes compared with prior images of the same described in Fig. 2c and d