A 31-year-old Hispanic male presented with a two-week history of metamorphopsias and painless vision loss in the left eye (OS). One month before, he had a flu-like illness with sore throat, fever, and a macular rash over his hands, feet and groin. Physical examination revealed small vesicles in a resolving phase on both hands and right foot [Fig. 1]. Best-corrected visual acuity (BCVA) was 20/80 in the OS and 20/20 in the right eye (OD). Fundoscopy of the OD showed a subretinal temporal extrafoveal whitish lesion with surrounding punctate hemorrhages [Fig. 2a]. The OS showed three similar lesions; the largest, involving the fovea [Fig. 2b]. Fluorescein angiography (FA) of both eyes (OU) showed hyperfluorescent lesions with small hypofluorescent lesions corresponding to the punctate hemorrhages seen in fundus evaluation [Fig. 3]. Spectral-domain optical coherence tomography (SD-OCT) of the OD displayed a normal whitish band corresponding to an undamaged ellipsoid layer [Fig. 4a]. In the OS, SD-OCT showed hyperplasia of the retinal pigment epithelium (RPE) and disruption of the ellipsoid layer [Fig. 4b]. Due to the findings previously described and the recent viral prodrome, the diagnosis of AIM was suspected. A complement fixation testing for coxsackievirus antibody titers of B1 and B6 revealed a fourfold increase (titers 1:32; reference range < 1:8). With the diagnosis confirmed, we decided to establish conservative management with follow-up in a one-week basis. After four weeks, BCVA in the OS returned to 20/20.
Figure 1
(a) Small 1–2 mm vesicles (arrows) in a resolving phase are seen in both hands. (b) Confluent vesicles (arrowhead), also in a resolving phase, are seen in the right foot
Figure 2
Fundus photographs of both eyes at initial presentation. (a) Right eye showing an extra-foveal area of retinal edema with surrounding punctate intrarretinal hemorrhages. (b) Left eye showing three spots of retinal edema, one of them with foveal involvement, with surrounding intrarretinal hemorrhages and peripheral white without pressure areas
Figure 3
Fluorangiography (FA) images of both eyes. (a) Right eye early-phase image depicting hyperfluorescence resulting from a retinal pigment epithelium (RPE) area of staining. (c) Late-phase image showing dye pooling hyperfluorescence in the subneurosensory retina. (b) Left eye early-phase image showing hyperfluorescence with foveal surroundment from staining at RPE. (d) Late-phase FA revealing dye pooling withing the subneurosensory retina
Figure 4
Spectral-domain optical coherence tomography (SD-OCT) assessment of the horizontal plane in the macular region of both eyes. (a) Right eye showing normal whitish band (arrow) corresponding to the ellipsoid layer. (b) Left eye revealing hyperreflectivity within the fovea corresponding to retinal pigment epithelium hyperplasia (arrowhead). Also, disruption (gross arrow) and zones of absence (thin arrow) of the ellipsoid layer can be observed
(a) Small 1–2 mm vesicles (arrows) in a resolving phase are seen in both hands. (b) Confluent vesicles (arrowhead), also in a resolving phase, are seen in the right footFundus photographs of both eyes at initial presentation. (a) Right eye showing an extra-foveal area of retinal edema with surrounding punctate intrarretinal hemorrhages. (b) Left eye showing three spots of retinal edema, one of them with foveal involvement, with surrounding intrarretinal hemorrhages and peripheral white without pressure areasFluorangiography (FA) images of both eyes. (a) Right eye early-phase image depicting hyperfluorescence resulting from a retinal pigment epithelium (RPE) area of staining. (c) Late-phase image showing dye pooling hyperfluorescence in the subneurosensory retina. (b) Left eye early-phase image showing hyperfluorescence with foveal surroundment from staining at RPE. (d) Late-phase FA revealing dye pooling withing the subneurosensory retinaSpectral-domain optical coherence tomography (SD-OCT) assessment of the horizontal plane in the macular region of both eyes. (a) Right eye showing normal whitish band (arrow) corresponding to the ellipsoid layer. (b) Left eye revealing hyperreflectivity within the fovea corresponding to retinal pigment epithelium hyperplasia (arrowhead). Also, disruption (gross arrow) and zones of absence (thin arrow) of the ellipsoid layer can be observed
Discussion
The pathology of AIM is related to an inflammatory process involving the RPE of the macula and the outer retina after Coxsackie HFMD.[12] FA findings are characterized by focal hyperfluorescence from staining of the subretinal thickening of the RPE. SD-OCT features include RPE hyperplasia and disruption of the ellipsoid layer with or without neurosensory retinal detachment.[34] Ocular manifestations and posterior segment findings related to a viral prodrome found in AIM may be undistinguishable from other autoimmune, virus-related or idiopathic maculopathies, especially central serous chorioretinopathy (CSCR) and idiopathic choroidal neovascularization (CNV).[45] From the therapeutic point of view, distinguishing AIM from CSCR and CNV is of utmost importance. While the former is an auto-limiting process that resolves without therapeutic measures, the others require aggressive and prompt intervention to avoid potential sight-threatening complications.[3]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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