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Dengue associated choroiditis: a rare entity
© The Author(s). 2017
Received: 24 January 2017
Accepted: 16 May 2017
Published: 30 May 2017
We report a case of choroiditis during dengue fever.
A 35-year-old female presented with blurring of vision during dengue fever. Her fundus examination revealed yellow deep choroidal lesions at right macula, multiple small, yellowish subretinal macular dots along papillomacular bundle, and hyperemic disc. There was a small retinal hemorrhage at temporal margin of disc. The left eye had similar small discrete lesion superonasal and inferotemporal to macula.
We report a hitherto undescribed case of choroiditis in a dengue patient.
Dengue fever is a mosquito-borne Flavivirus infection in humans. The disease is endemic in the tropics, warm temperate regions of the world such as such as India, Southeast Asia, America, and the Western Pacific . Dengue eye disease has plethora of presentations and includes subconjunctival hemorrhage, anterior uveitis, intermediate uveitis, maculopathy, chorioretinitis, neuroretinitis, and panuveitis . We describe here an interesting case of a young lady who presented with choroidal involvement during dengue fever.
Posterior segment involvement such as retinitis, retinochoroiditis , retinal vasculitis , and neuroretinitis  in dengue has been reported extensively in literature. Retinochoroiditis in dengue was reported by Tabbara  who found multiple foci of retinochoroiditis, vasculitis, cotton-wool spots, and retinal hemorrhages in two patients infected with dengue. Pathogenesis of ocular involvement in dengue is not completely understood and believed to be multifactorial. Thrombocytopenia and immune-mediated mechanisms are thought to play an important role . Dengue maculopathy is perhaps the most recognized manifestation of ocular involvement in dengue. Macular edema , retinal vasculitis , macular hemorrhage, and exudative retinal detachment have been frequently described in association with dengue maculopathy. Foveolitis is characterized by a discrete, well-defined yellow-orange subretinal lesions in the fovea, which usually corresponds to disruption of the outer neurosensory retina and the inner segment/outer segment (IS/OS) junction. Hallmark feature described in these patients was the presence of central scotomata [3, 6], which was reported in absence of macular oedema also. Optic nerve involvement in dengue is not uncommon. In a study of 41 patients of dengue-associated maculopathy by Bacsal et al. , 11% of the patients had disc oedema.
The key clinical feature in this case is the presence of choroidal inflammation. The choroiditis in our patient was multifocal, and the patient was investigated to rule out serpiginous-like choroiditis. Her laboratory investigations were non-contributory to the cause of inflammation including tuberculin skin test, interferon gamma release assay and high-resolution computed tomography (HRCT) chest. Presence of hard exudates along papillomacular bundle and OCT findings suggest involvement of overlying retina with subretinal fluid and retinal edema. Unfortunately, we could not perform indocyanine angiography due to systemic condition of the patient. There was no relative afferent pupillary defect, and color vision of the patient was normal. However, deposition of hard exudates in the form of a partial, nasal macular star configuration in the right eye may also be due to optic nerve involvement. The retinal hemorrhage noticed at the temporal margin of the optic disc in right eye can be due to the endothelial cell damage by the dengue virus.
Nevertheless, we believe that our case represents a rare clinical manifestation in wide-spectrum of dengue eye disease. Tabbara  reported two patients who developed multiple foci of retinochoroiditis, vasculitis, cotton wool spots, and retinal hemorrhages following dengue fever that resolved spontaneously. Our patient had predominantly choroiditis, and we did not observe any cotton wool spot or vasculitis. One of the patients reported by Tabbara , developed macular scarring resulting in poor vision in that eye. Our patient responded well to oral steroid, though she complained of persistence of scotoma even after resolution of her lesions. Exact mechanism of choroiditis in our patient is not clear. Direct cell damage by the dengue virus leading to the apoptosis and dysfunction of the affected cells has been described in literature . Also immune-mediated injury may have played an important role in dengue fever associated choroiditis, similar to foveolitis  and dengue-associated maculopathy . Our case highlights the importance of oral steroid in patients with macula threatening lesion in dengue-associated eye disease. In conclusion, our case presents a rare clinical variant of ocular involvement in dengue fever.
HMY, PDM, and JB contributed to patient management, literature review, and preparation of the manuscript. PDM and JB provided the concept and design, intellectual content, and critical review of the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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