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Case Reports
. 2021 Apr 12;12(1):164-168.
doi: 10.1159/000513108. eCollection 2021 Jan-Apr.

The Diagnostic Conundrum of Retinitis and a Pigmented Scar

Nikhila S Khandwala  1 , Jason M L Miller  1 , Robert A Hyde  1 , Christopher D Conrady  1 , Rajesh C Rao  1 , Cagri G Besirli  1
Affiliations
Case Reports

The Diagnostic Conundrum of Retinitis and a Pigmented Scar

Nikhila S Khandwala et al. Case Rep Ophthalmol. .

Abstract

We report a finding of a pigmented chorioretinal scar with acute retinal necrosis (ARN) caused by herpes simplex virus 2 (HSV-2) infection rather than toxoplasma, creating an initial diagnostic dilemma. A 53-year-old functionally monocular male presented with painless floaters and blurry vision in his seeing eye over a period of 4 days. An exam demonstrated anterior chamber (AC) reaction, vitritis, multifocal patches of whitening, and an occlusive retinal vasculitis. A superior pigmented chorioretinal scar with overlying contracted vitreous was noted in the periphery with no adjacent retinal whitening. The patient was treated for both ARN and toxoplasma chorioretinitis until PCR study of the vitreous and AC returned positive for HSV-2 and negative for toxoplasmosis. Management consisted of a dual therapy regimen of both oral and intravitreal antiviral agents as well as oral corticosteroids. The patient's clinical course was complicated by rhegmatogenous retinal detachment within 2 weeks after symptom onset, requiring pars plana vitrectomy with silicone oil and intraoperative intraocular incubation with foscarnet. We review emerging evidence for pigmented chorioretinal scars in ARN specifically caused by HSV-2, as well as diagnostic and treatment dilemmas in the management of ARN and ARN detachments.

Keywords: Acute retinal necrosis; Herpes simplex virus 2; Pigmented chorioretinal scar; Retinal detachment; Toxoplasma uveitis.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Fig. 1
Fig. 1
a Color fundus photograph demonstrating a pigmented chorioretinal scar (outlined by white box) superior to the arcade with overlying contracted vitreous (Note: enhanced inset view of pigmented chorioretinal scar is postsurgical as demonstrated by surrounding laser photocoagulation scars since clear preoperative views were limited by vitritis). Annotations include optic disc (yellow arrow), macula (yellow star), occlusive vasculitis (blue arrows), and multifocal retinal whitening (red arrows). b Fluorescein angiography demonstrating severe occlusive vasculitis in the temporal periphery.
Fig. 2
Fig. 2
a Color fundus photograph on the day of the patient's fourth foscarnet injection (white arrow indicates pigmented scar). b Color fundus photograph 12 h later demonstrating large tear and focal detachment of the retina in the area of temporal necrosis (blue arrow) with superior pigmented lesion (white arrow).
See this image and copyright information in PMC

References

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