{"id":4376,"date":"2023-08-17T14:26:47","date_gmt":"2023-08-17T14:26:47","guid":{"rendered":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/?p=4376"},"modified":"2024-08-28T13:17:27","modified_gmt":"2024-08-28T13:17:27","slug":"pesky-papilledema","status":"publish","type":"post","link":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/volume1-issue2\/pesky-papilledema\/","title":{"rendered":"Pesky Papilledema"},"content":{"rendered":"

doi: 10.62055\/jxblodhjmfxt<\/a><\/p>\n

<\/h2>\n

INTRODUCTION:<\/h2>\n

Welcome to the \u201cNeuro Nuggets\u201d<\/strong> column within the Journal of Medical Optometry (JoMO)!\u00a0 This column aims to make neuro-ophthalmic disease more approachable by blending real-world clinical cases with evidence-based medicine.\u00a0 The patient in this edition\u2019s column has been well-known in our clinic for many years and helps to highlight a lesser-known mechanism for papilledema.\u00a0 Enjoy!<\/p>\n

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CASE PRESENTATION:<\/h2>\n

A 41 y.o. Black female presented with a constellation of symptoms.\u00a0 She noticed intermittently blurred \u201cfuzzy\u201d vision in both eyes lasting less than one hour in duration for the preceding few months.\u00a0 The patient also noted peripheral numbness with a tingling sensation in her arms and legs, occasional nausea, and headaches (bilateral temporal in location, variable severity).\u00a0 The patient\u2019s past medical history included testing positive for human immunodeficiency virus (HIV+) dating back 20 years prior to presentation.\u00a0 Of note, the patient had discontinued her prescribed HIV medications for several months prior to presentation due to fear of side effects.\u00a0 The patient\u2019s body mass index was 25.<\/p>\n

On examination, the patient\u2019s best-corrected visual acuity was 20\/20 in each eye.\u00a0 Color vision by Ishihara was intact in each eye.\u00a0 Pupils were reactive without any afferent pupillary defect.\u00a0 Ocular motility evaluation was normal.\u00a0 Visual field testing (HVF 24-2 SITA Fast) was full\/intact and normal in the right eye, and there was a mildly enlarged blind spot but otherwise intact visual field in the left eye.\u00a0 Slit lamp exam and intraocular pressure were normal in each eye.\u00a0 There was evidence of moderate optic disc edema and associated peripapillary hemorrhages in each eye (FIGURE 1<\/strong>).<\/p>\n

\"fig<\/a><\/p>\n

MRI brain with\/without contrast was normal, with no evidence of mass, hemorrhage, or cerebral venous sinus thrombosis.\u00a0 Lumbar puncture (LP) in the lateral decubitus position was measured as 31 cm H2O.\u00a0 Cerebrospinal fluid (CSF) analysis showed elevated white cells (97% lymphocytes), elevated protein, and normal glucose.\u00a0 An extensive battery of infectious disease serologies and CSF studies showed no evidence of infection (TABLE 1<\/strong>) aside from the patient\u2019s known HIV status.\u00a0 The patient\u2019s HIV viral load at presentation was 31,600 copies\/mL with a CD4 count of 146 cells\/microliter on serologic testing.<\/p>\n

 <\/p>\n

\"pesky<\/a><\/p>\n

 <\/p>\n

The patient was urged to resume HIV therapy and was restarted on efavirenz and emtricitabine\/tenofovir.\u00a0 One month after resuming HIV therapy, the patient\u2019s exam demonstrated resolution of the optic disc edema (FIGURE 2<\/strong>).\u00a0 Visual acuity remained intact, and visual field testing normalized to baseline.\u00a0 On follow-up lab work, the patient\u2019s HIV viral load was not detected, and the CD4 count ultimately normalized to 628 cells\/microliter.\u00a0 The patient has now been followed for 18 years since the initial presentation, and her vision has remained intact without any recurrence of optic disc edema in either eye.<\/p>\n

\"fig<\/a><\/p>\n

 <\/p>\n

DISCUSSION:<\/h2>\n

HIV has been reported to impact the optic nerves and visual pathway through several different mechanisms.\u00a0 First, the HIV virus itself can impact optic nerve function via direct viral infection contributing to axonal degeneration as well as from the effects of associated inflammatory mediators.1<\/sup>\u00a0 Second, HIV can render an individual susceptible to secondary infection from a host of pathogenic mechanisms (i.e., Cryptococcus or syphilis infection), resulting in infectious optic neuropathy.1<\/sup>\u00a0 Third, HIV is reported to alter CSF composition and can contribute to intracranial hypertension with resultant papilledema,1<\/sup>\u00a0as demonstrated in this case.<\/p>\n

The HIV virus contributes to CSF pleocytosis (increased cell count), which increases CSF viscosity and decreases outflow, thereby elevating the intracranial pressure.1<\/sup>\u00a0 Elevated intracranial pressure is transmitted along the optic nerve\/sheath and often manifests with clinical evidence of optic disc edema.\u00a0 Of note, intracranial hypertension may be the only clinical sign of HIV infection,2<\/sup>\u00a0and clinicians should consider including this test in their work-up for patients presenting with optic disc edema.<\/p>\n

Importantly, this patient\u2019s CSF analysis was abnormal, with elevated protein and cell counts.\u00a0 Therefore, a diagnosis of idiopathic intracranial hypertension could not be made based on current clinical criteria.3<\/sup>\u00a0 While this patient\u2019s optic disc edema improved after resuming anti-retroviral therapy alone, others may go on to require medications or surgery to normalize their intracranial pressure.\u00a0 This case helps illustrate the importance of properly recognizing the underlying mechanism of intracranial hypertension to guide appropriate management.\u00a0 Clinicians should maintain a low threshold to consult with infectious disease providers in HIV+ patients presenting with neuro-ophthalmic disease.<\/p>\n

 <\/p>\n

CLINICAL PEARLS:<\/h2>\n
    \n
  • High levels of HIV viral load are thought to contribute to CSF pleocytosis, increase CSF viscosity, and decrease CSF outflow.<\/li>\n
  • Eye care providers should be aware of the potential for HIV to contribute to elevated intracranial pressure and result in papilledema.<\/li>\n
  • In addition to retinopathy, HIV may cause optic neuropathy.<\/li>\n<\/ul>\n

     <\/p>\n

    REFERENCES:<\/h3>\n
      \n
    1. Lynn K. Gordon & Helen Danesh-Meyer. Neuro-Ophthalmic Manifestations of HIV Infection, Ocular Immunology and Inflammation. 2020. 28:7, 1085-1093, DOI: 10.1080\/09273948.2019.1704024<\/li>\n
    2. Alqahtani et al. Acute HIV Infection Masquerading as Idiopathic Intracranial Hypertension: A Case Report and Literature Review. Case Rep Neurol 2020. 12:56. DOI: 10.1159\/000505721,<\/li>\n
    3. Chen et al.\u00a0 Expanding the clinical spectrum of idiopathic intracranial hypertension. Curr Opin Neurol. 2023, 36:43\u201350, DOI:10.1097\/WCO.0000000000001131.<\/li>\n<\/ol>\n

       <\/p>\n

      The author has no financial disclosures, and no sponsorship or funding was involved in this work.<\/p>\n","protected":false},"excerpt":{"rendered":"

      A 41 y.o. Black female with HIV presented with intermittently blurred \u201cfuzzy\u201d vision in both eyes, peripheral numbness, nausea, and headaches…<\/p>\n","protected":false},"author":19,"featured_media":4124,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"79","_seopress_titles_title":"","_seopress_titles_desc":"A 41 y.o. Black female with HIV presented with intermittently blurred \u201cfuzzy\u201d vision in both eyes, peripheral numbness, nausea, and headaches...","_seopress_robots_index":"","_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"categories":[61,44,94,79],"tags":[],"class_list":["post-4376","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-neuro","category-neuro-nuggets","category-optic-nerve","category-volume1-issue2","et-has-post-format-content","et_post_format-et-post-format-standard"],"_links":{"self":[{"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/posts\/4376","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/users\/19"}],"replies":[{"embeddable":true,"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/comments?post=4376"}],"version-history":[{"count":3,"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/posts\/4376\/revisions"}],"predecessor-version":[{"id":5016,"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/posts\/4376\/revisions\/5016"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/media\/4124"}],"wp:attachment":[{"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/media?parent=4376"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/categories?post=4376"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/wp-json\/wp\/v2\/tags?post=4376"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}