Acute macular neuroretinopathy in a patient with acute myeloid leukemia and deceased by COVID-19: a case report

Abstract

Purpose: Acute macular neuroretinopathy (AMN) is a visual-deteriorating rare clinical entity with an uncertain etiology. We aimed to report a case of AMN and underlying disease of acute myeloid leukemia (AML).

Case presentation: A thirty-five-year-old female patient with bone marrow biopsy confirmed AML, and bicytopenia, under chemotherapy, complained of sudden paracentral visual field defect in her right eye was referred. Visual acuity was 20/20 in both eyes. Posterior segment evaluation revealed multiple Roth's spots. Optical coherence tomography (OCT) demonstrated hyper-reflectivity band, in the outer nuclear layer and outer plexiform layer, nasal to the fovea of the right eye, and hyperreflective patch in outer retina segmentation en-face OCT, suggestive of the diagnosis of AMN. Nine days after AMN diagnosis, dyspnea, malaise, and cough was initiated. Ground glass opacities in lung CT scan, beside reverse transcription polymerase chain reaction of severe acute respiratory syndrome coronavirus-2, was conclusive of coronavirus disease 2019 (COVID-19). The patient deceased after 6 days.

Conclusion: We report a rare case of AMN following AML. Our findings support the role of ischemia in the outer retina, of which AML may contributed to the pathophysiological process. The patient has deceased less than 2 weeks from AMN initiation.

Keywords: Acute macular Neuroretinopathy; Acute myeloid leukemia; Coronavirus disease 2019; Severe acute respiratory syndrome Coronavirus-2.

Fig. 1

a, b Bone marrow biopsy result compatible with AML showing a hypercellular marrow with excess of immature myeloid cells. c, d Bone marrow aspiration shows blast cells are large in size and had a high nucleus/cytoplasm ratio, monocytoid aspect, and blue-gray cytoplasm. e Chest CT-scan at the admission, normal without opacities. f Chest CT- scan after COVID-19 involvement

Fig. 2

a, b: Blue autofluorescence imaging shows multiple hypoautofluorescence lesions in both eyes, corresponding intraretinal hemorrhages and Roth’s spots; and normal hypoautofluorescence of the fovea. Small mild hyperautofluorescence area in the papilomacular bundle area is seen, corresponding to the area with acute macular neuroretinopathy involvement, and blockage of the normal autofluorescence of the underlying RPE. c, d: Near infra-red reflectance imaging showing hyporeflective lesion in the papillomacular area of the right eye and multiple drop like hyporeflective areas associated with Roths spots. e, f Spectral domain-optical coherence tomography (OCT) demonstrated hyper-reflectivity of the outer nuclear layer (ONL) and outer plexiform layer (OPL) associated with attenuation of the ellipsoid zone (EZ) nasal to the fovea of the right eye. g OCT demonstrated epiretinal hemorrhage of the right eye, corresponding to the clinical Roth’s spot. h Normal macular OCT of the left eye

Fig. 3

Spectral domain 6 × 6 mm optical coherence tomography angiography (OCTA) (a-d) and en-face optical coherence tomography (OCT) (e-h) scan of the right eye macula, at superficial retina (a, e) deep retina (b, f), outer retina (c, g), and choriocapillaris (d, h) slab selection. At the outer retina slab selection, en-face OCT showed hyperreflective patch (*), corresponding to the edema of the outer retina at the acute macular neuroretinopathy involvement