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Acute necrotizing panophthalmitis in seropositive case of Chikungunya:

A case report and review of literature

Pratyush Ranjan, Brahm P Guliani, Moncef Khairallah1, Deepak Mishra2

We are reporting a case of acute necrotizing panophthalmitis associated with serologically proven Chikungunya Access this article online
infection. A young male with a history of fever and joint pain presented to our department with sudden painful proptosis Website:
of 6 hours. A detailed ocular examination and specialized serological, imaging, and histopathological tests were www.jcor.in
performed. Imaging studies revealed dislocated lens, suprachoroidal and vitreous hemorrhage, total retinal detachment DOI:
and choroidal detachment and soft tissue edema of orbit. Although the Chikungunya virus was not isolated from ***
vitreous tap, chorioretinal biopsy, and other eviscerated material,the serological studies were positive with high titer of Quick Response Code:
recent Chikungunya infection. Histopathology of chorioretinal biopsy and uvea shows acute necrotizing inflammation.
Acute necrotizing panophthalmitis (ANP) can be one of the ocular manifestations of Chikungunya infection and was
devastating in the present case.

Key words: Chikungunya, chorioretinal biopsy, necrotizing, panophthalmitis

Chikungunya is a mosquito-borne disease, caused by alpha virus,
of family Togaviridae. The presentation of disease is sudden with
high-grade fever, rash, and severe arthralgia of the small joints of
hands and toes. Ocular involvement in Chikungunya is manifold,
but is self-resolving and without squeale.[1] We report a case of
serologically proven Chikungunya infection that manifested with
acute fulminant panophthalmitis, which resulted in a painful blind
eye, necessitating evisceration.
corneal haze, and total hyphema [Figure 2]. Fundal details were not
visible. The proptosis was 3 mm in size, axial, non-compressible,
and tender on compression. Ocular movements were painful and
restricted in all the directions. On digital tension, left eye appeared
soft and tender. A provisional diagnosis of acute panophthalmitis
associated with seropositive Chikungunya was made.

Case Report
A 35-year-old male presented to department of ophthalmology,
Safdarjung Hospital, New Delhi, India with painful, progressive
proptosis of left eye with visual loss developing over 6 hours.
Patient had no ocular complaints 6 hours back. He had a history of
high-grade fever, purpuric rash, and severe joint pain in preceding
5 days. He was diagnosed with Chikungunya based on classical
clinical presentation and positive serology tests and was treated
symptomatically with paracetamol tablets 500 mg thrice daily. Figure 1: Showing proptosis and lid oedema of left eye
The fever subsided on fifth day, but on sixth day, he developed
painful progressive proptosis with loss of vision in the left eye
over a period of 6 hours; this is when he presented to us.
Results of clinical examination of the right eye were
unremarkable with a visual acuity of 6/6. On examination of left
eye, visual acuity was no light perception. There were swelling
and redness of both eyelids, raised temperature over the lids, and
proptosis [Figure 1]. Forcible opening of eyelids revealed chemosis,

Department of Ophthalmology, Vardhman Mahavir Medical College

and Safdarjung Hospital, New Delhi, 1Department of Ophthalmology,
Fattouma Bourguiba University Hospital, Monastir, Tunisia 2Regional
Institute of Ophthalmology, Indira Gandhi Institute of Medical Sciences,
Patna, Bihar, India
Address for correspondence: Dr. Pratyush Ranjan, Regional
Institute of Ophthalmology, Sitapur, Uttar Pradesh, India. E-mail:
drpratyushranjan@gmail.com
Manuscript received: 13.09.2012; Revision accepted: 07.11.2012 Figure 2: Showing chemosis and corneal haze left eye

Journal of Clinical Ophthalmology and Research - Jan-Apr 2013 - Volume 1 - Issue 1 23

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Brief Communications
Systemic examination revealed no other organ involvement.
Blood parameters for complete blood count, serum urea
and creatinine, serum electrolytes, urine microscopy and
biochemistry, and fasting and post-prandial blood sugars
were within normal limits. Serum IgM antibodies against
Chikungunya virus were strongly positive. Serology for malaria,
dengue, typhoid, and human immunodeficiency virus (HIV)
was negative. Ultrasonography of left eye showed vitreous
hemorrhage, total retinal detachment, and choroidal detachment
with thickening of the orbital contents. Ultrasonography of
right eye was normal.
Contrast-enhanced computed tomography (CT) scan orbit
and brain showed left sided proptosis of 3.2 mm, uveal sclera
rim thickened and enhancing. Size of the eyeball and vitreal
densities was preserved. Lens density was unremarkable. Posterior
orbital intra-conal facial plane was preserved. Optic nerve sheath
complex was normal. Right orbit and contents appear normal.
CT scan of brain was unremarkable. Vitreous tap sent for gram
staining and potassium hydroxide (KOH) preparation showed no
organism. Vitreous culture and polymerase chain reaction (PCR)
for pan microbial screen were also negative.
The patient was managed symptomatically with topical
moxifloxacin 0.5%, homatropine 2%, intravitrealvancomycin
(1mg in 0.1ml) and amikacin (0.4mg in 0.1ml), intravenous
antibiotics (augmentin 1.2 gms, metronidazole 500 mg thrice
daily and amikacin 500 mg twice daily) for 5 days, but he showed
no response He was started on oral steroids (60 mg once daily)
after 5 days of above mentioned therapy but his proptosis and
pain worsened despite treatment.
A contrast-enhanced magnetic resonance imaging (MRI) of
orbit [Figure 3] was done on day 4 of presentation, as patient was
a b
c d
Figure 3: (a) Contrast Enhanced MRI showing dislocated lens (arrow)
surrounded by vitreous hemorrhage (hypointense on T2W) (b) Contrast
Enhanced MRI of head and orbit (T1W) showing proptosis (arrow) of
left eye (c) Contrast Enhanced MRI of head and orbit (T1W) showing
thickened uveal tissue (hollow arrow) and thickened muscles (solid
arrow) (d) Enhanced MRI of head and orbit (T1W) showing disorganized
mass (arrow)
24
not responding to treatment and his pain and swelling of lids
were still present and increasing without any improvement in
vision. MRI scan of orbit showed proptosis in left eye measuring
5.8 mm, total retinal detachment, inflammation of intraconal and
extraconal fat tissue, enhancing on post-godolinium sequence,
vitreous hemorrhage (hypodesnse signal on T2W, blooms on
FFE) and a dislocated lens was seen in posterior chamber. All
extra-ocular muscles were showing signs of inflammation, with
enhancement near its tendenous attachments. Uveal and sclera
tissue were also showing sign of inflammation along with optic
nerve (intra-orbital and proximal extra-orbital part). Right eye
was normal.
A decision to eviscerate his left eye was taken in view of
enlarging proptosis and painful blind left eye. Chorioretinal biopsy
followed by evisceration was done. Chorioretinal and uveal tissue
were sent for RT-PCR and histopathological examination to Larsen
and Turbo Ocular Pathology Department of ShankaraNethralaya,
Chennai, India and Indian Council for Medical research, New Delhi,
India. Virus isolation and serology was done at National Center
for Disease Control, New Delhi, India (also a regional center for
CDC, Atlanta, USA).
Histopathology of chorioretinal and uveal tissue showed dense
infiltration of polymorphonuclear leukocytes, lymphocytes, and
eosinophilic exudates. It also showed portion of sclera with areas
of hemorrhage, necrosis, and infiltration of acute inflammatory
cells [Figure 4]. RT PCR done on preserved ocular tissue was
negative for chikungunya. Virus isolation studies were negative
on the eviscerated material.
Discussion
Chikungunya is a multisystem viral disease. It is often thought to
be associated with mild ocular complaints, which include retro-
orbital pain, conjunctival congestion, and photophobia.[2] There
was an explosive outbreak of chikungunya in 2005, which affected
more than a million people in Indian Ocean region. Contrary to the
earlier epidemics that were caused by Asian strain of chikungunya,
these outbreaks were due to a new strain East Central South (ECS)
African genotype.[3] During and after the outbreak of 2005, severe
ocular involvement was reported, which included episcleritis,
Figure 4: Chorioretinal biopsy showing uveal inflammation (hollow
arrow), scleral necrosis (solid arrow) and magnified view (star)
Journal of Clinical Ophthalmology and Research - Jan-Apr 2013 - Volume 1 - Issue 1
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Brief Communications

granulomatous and non-granulomatous anterior uveitis, retinitis,
and optic neuritis. Visual prognosis was good with most patients
recovering good vision.[4-6] A typical ocular manifestations reported
in literature include of bilateral macular choroiditis[7] and Fuchs’
heterochromiciridocyclitis post-chikungunya infection.[8] There is
no specific anti-viral therapy for chikungunya, but corticosteroids
accelerate recovery.
The diagnosis of chikungunya is based on either specific
serology or detection of viral RNA by RT- PCR, it is positive during
viremic phase [109 - 1012 viral RNA per ml of blood] lasting for one
week after symptom onset,while the elevated levels of IgG and
IgM can last even for months.[9,10] Virus isolation studies are gold
standard for diagnosis but not always possible.[10] In our patient,
chikungunya virus was neither isolated from ocular tissue nor
from ocular fluid.
Panophthalmitis in seropositive chikungunya has never been
reported in literature to the best of our knowledge. We propose
that panophthalmitis in seropositive chikungunya is acute in
onset with a rapid fulminating course, and acute necrotizing
panophthalmitis (ANP) can be one of the ocular manifestations
of chikungunya infection.
Acknowledgements
Dr. Jyotirmay Biswas, Director – Uveitis & Ocular Pathology Department,
Sankara Nethralaya, Chennai, INDIA for critically discussing the case and
providing thoughtful inputs and agreeing to perform the RT-PCR and
review histopathology at his institution.
Dr. Shashi Khare, Additional Director and Head of department,
Department of Microbiology, National center for Disease Control (NCDC),
New Delhi, India for taking personal interest and agreeing do a variety
of specialized tests at her institution.
of Pathology, Indian Council of Medical Research (ICMR), New Delhi, India
for taking personal interest and working long hours for this case.
References
1. Khairallah M, Jelliti B, Jenzeri S. Emergent infectious uveitis.
Middle East Afr J Ophthalmol 2009;16:225-38.
2. Sudeep AB, Parashar D. Chikungunya: An overview. J Biosci
2008;33:443-9.
3. Mahendradas P, Ranganna SK, Shetty R, Balu R, Narayana KM,
Babu RB, et al. Ocular manifestations associated with chikungunya.
Ophthalmology 2008;115:287-91.
4. Mahesh G, Giridhar A, Shedbele A, Kumar R, Saikumar SJ. A
case of bilateral presumed chikungunyaneuroretinitis. Indian J
Ophthalmol 2009;57:148-50.
5. Murthy KR, Venkataraman N, Satish V, Babu K. Bilateral
retinitis following chikun-gunya fever. Indian J Ophthalmol
2008;56:329-31.
6. Mittal A, Mittal S, Bharati MJ, Ramakrishnan R, Saravanan S, Sathe
PS. Optic neuritis associated with chikungunya virus infection in
South India. Arch Ophthalmol 2007;125:1381-6.
7. Chanana B, Azad RV, Nair S. Bilateral macular choroiditis
following Chikungunya virus infection. Eye (Lond) 2007;
21:1020-1.
8. Mahendradas P, Shetty R, Malathi J, Madhavan HN. Chikungunya
virus iridocyclitis in Fuchs’ heterochromiciridocyclitis. Indian J
Ophthalmol 2010;58:545-7.
9. Wang E, Paessler S, Aguilar PV, Carrara AS, Ni H, Greene IP, et al.
Reverse transcription-PCR-enzyme linked immunosorbent assay
for rapid detection and differentiation of alphavirus infections.
J Clin Microbiol 2006;44:4000-8.
10. Edwards CJ, Welsch SR, Chamberlain J, Hewson R, Tolly H, Cane
PA, et al. Molecular diagnosis and analysis of chikungunya virus.
J Clin Virol 2007;39:271-5.
Cite this article as: Citation will be included before issue gets online***

Source of Support: Nil. Conflict of Interest: None declared.

Dr. Usha Agrawal, Deputy Director, Department of Pathology, Institute

Steroid-responsive serous retinal detachment in undetected chronic

lymphocytic leukemia

Veeresh Korwar, Soumyava Basu

A 69-year-old diabetic man, treated intermittently with oral and periocular corticosteroids for suspected left eye Access this article online
choroiditis for past one year, presented with decreased vision in left eye. We noted best-corrected visual acuity (BCVA) Website:
of 20/35 and 20/30 in right and left eyes, respectively. Right lens was cataractous and left pseudophakic. Right fundus www.jcor.in
was normal while left showed shallow serous detachment around optic disc with underlying focal choroidal lesions. DOI:
Blood investigations revealed markedly raised leukocyte count with marked lymphocytosis. Bone marrow cytology ***
confirmed B-cell chronic lymphocytic leukemia. The patient’s ocular and systemic condition resolved with rituximab Quick Response Code:
and bendamustine chemotherapy.

Keywords: Chronic lymphocytic leukemia, corticosteroids, serous retinal detachment

Retina-Vitreous Services, LV Prasad Eye Institute, Bhubaneswar,

Orissa, India
Address for correspondence: Dr. Soumyava Basu, LV Prasad Eye
Institute, Bhubaneswar-751024, Orissa, India. E-mail: eyetalk@
gmail. com
Manuscript received: 29.09.2012; Revision accepted: 07.11.2012

Journal of Clinical Ophthalmology and Research - Jan-Apr 2013 - Volume 1 - Issue 1 25