We report the case of a 24-year-old male who came to the emergency department with bilateral VA decrease and headache for two days.
As remarkable personal history, the patient reported a flu-like illness the previous week, treated with ibuprofen 600 mg. On examination, the right eye VA was blisters and the left eye VA was 0.05.
Pupils are isochoric and normoreactive and the biomycosis of the anterior pole is normal.
We observed confluent white-gray lesions in the posterior pole in both eyes that affect the fovea.
Late suspicion of APPEMA, a fluorescein angiography (FFA) was performed, where areas of hypofluorescence marked in early times that become areas of hyperfluorescence are observed.
Indocyanine green angiography (ICG) shows areas of hypofluorescence in the choroid corresponding to placoid lesions that are related to choroidal hypoperfusion accompanying this pathology.
Optical coherence tomography (OCT) shows thickening of the mental axis with hyperresponsiveness at the level of the outer layers.
Oral corticoid treatment was started (prednisone 60 mg), which lasted for one week.
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On the other hand, the patient complained of severe headache that improved with corticoid treatment and that reappeared when the medication was discontinued, therefore when cerebral vasculitis was suspected, which was occasionally associated with magnetic resonance angiography.
A histocompatibility study of HLA B-7 and HLA DR2, which was positive, was requested.
As for the evolution, visual acuity improved paulatinely but at one month of follow-up the patient reported diplopia in the distant vision.
On physical examination, a paralysis of the VI right cranial nerve was observed, with limitation of fixation of the right eye, which was confirmed by the Hess-Laster test.
A botulinum toxin injection was performed in the middle rectum of the right eye and one week later diplopia disappeared.
Currently, diplopia has reached 0.7 in right eye and 0.8 in left eye.
OCT showed recovery of foveal architecture, but increased reflectivity in both eyes.
