Background
Coronavirus disease (COVID-19) is a new disease that can potentially be fatal and
affect the lungs and airways. The virus is thought to be most likely transmitted by
an interspecies jump from bats to intermediate hosts and from animal hosts to humans
[1]. COVID-19, which is highly contagious and often manifests itself with fever, cough,
weakness, muscle pain, and shortness of breath, is thought to be transmitted mainly
through droplets in the environment as a result of contact with infected patients
[2], [3]. It has been reported that COVID-19 caused by severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), which infects host cells using renin angiotensin-converting
enzyme 2 (ACE2) receptors, which are widely expressed in the body, causes tissue hypoperfusion
and thrombosis in different stages of the disease by causing endothelial cell inflammation
and dysfunction [4], [5], [6], [7].
In this study, we aimed to present a case that developed retinal vasculitis in the
early period after a SARS-CoV-2 infection, which causes COVID-19.
Case Report
A 37-year-old male patient presented to our ophthalmology outpatient clinic with a
complaint of vision loss in the right eye for about 2 weeks. It was found that the
patient did not have any systemic disease such as diabetes mellitus or hypertension
in his history, but a diagnosis of COVID-19 was made in the reverse transcriptase-polymerase
chain reaction (PCR) analysis 1 month prior. In the patientʼs examination, best-corrected
visual acuity was 20/100 in the right eye and 20/20 in the left eye, respectively.
Both anterior segments were normal. Intraocular pressure was measured as 14 mmHg in
both eyes. On fundus examination, vitritis was found in the right eye. In addition,
while the optic disc was observed normally, there was vasculitis in the lower nasal
vessel arcuate ([Fig. 1 a]). The patientʼs left eye fundus examination was normal. In the fundus fluorescein
angiography (FFA), vasculitis was detected in the right eye ([Fig. 1 b]), while the left eye was normal. While retinal hyperreflective lesions in the outer
nuclear layer were detected in the right eye on optical coherence tomography (OCT),
OCT findings were found to be normal in the left eye ([Fig. 2 a, b]).
Fig. 1 Vasculitis image (see arrows) in a color fundus photograph (a, left) and FFA in the right eye (b, right).
Fig. 2 Retinal hyperreflective lesions (see arrows) in the outer nuclear layer were detected
in the right eye on OCT (a, left), while normal OCT findings were seen in the left eye (b, right).
In the systemic study of the patient, a TORCH (toxoplasma, rubella, cytomegalovirus,
herpes simplex virus) panel, Rose Bengal (brucella), pathergy test (for the diagnosis
of Behçetʼs disease), syphilis, and HIV tests as well as ANCA, dsDNA, and antiphospholipid
antibodies were found to be normal. Red blood cell count (5.25 10e6/uL) and hemoglobin
(15.1 g/dL) were found to be increased in the complete blood count, while other values
were normal. Biochemical parameters, except C reactive protein (0.63 mg/dL), were
within normal limits. Among the coagulation parameters, APTT, PT, and INR were within
normal limits, while fibrinogen (431.03 mg/dL) was found to have a high value. There
was no involvement in the chest X-ray of the patient, and sarcoidosis was excluded
in the patient as a result of chest diseases consultation.
Before applying to our clinic, the patient was diagnosed with Covid-19 in the PCR
test performed after complaints of fever, cough, weakness, and muscle pain, and the
patient was quarantined at home for 10 days without hospitalization. In the second
test performed on the 10th day afterwards, the PCR test was negative. Therefore, the
patient was diagnosed with COVID-19-associated vasculitis. Then, methylprednisolone
was administered in 1 g pulse for 3 days and 1 mg/kg afterward. On the 3rd day of
the treatment, it was observed that the patientʼs best-corrected visual acuity increased
to 20/25.
Discussion
Studies have reported that COVID-19 is associated with systemic vasculitis as well
as lung, liver, kidney, and skin involvement. Although it has been reported in experimental
studies that ophthalmologic diseases such as retinitis and optic neuritis can be seen
in this infection, there are limited studies on this subject [8], [9]. ACE2, the cellular receptor of SARS-CoV-2, has been reported to exist in ocular
tissues such as aqueous humor and retina in humans. In addition, SARS-CoV-2 viral
RNA was shown in retinal biopsy samples of patients [4]. It was reported that subtle cotton wool spots and microhemorrhages were seen in
the retina of patients with COVID-19 [10].
In this case, it was found that the patient developed vasculitis 2 weeks after the
SARS-CoV-2 infection. These findings are consistent with a recent study that reported
that retinal vein occlusion developed with vasculitis 10 days after infection [11]. Vasculitis developing due to SARS-CoV-2 infection may be secondary to either the
“cytokine storm” or the immune reaction against virus particles. Similarly, in some
viral diseases that cause retinal vasculitis, it has been reported that a delayed
immune response against viral antigens may play a role in the pathogenesis of the
disease [12], [13].
In a study examining COVID patients with normal visual acuity and no signs of intraocular
inflammation, subtle cotton wool spots and microhemorrhages along the retinal arcade
were reported. In this study, hyperreflective lesions at the level of the ganglion
cell and inner plexiform layers were also detected in both eyes of all patients included
in the study [14]. In our study, this is consistent with both hyperreflective lesions the outer nuclear
layer detected on OCT.
In conclusion, in this case, vasculitis, which we detected in the early period after
COVID-19, may be important in terms of revealing the necessity of close follow-up
of the patients in terms of decreasing the morbidity and mortality that may occur
as a result of systemic vascular pathologies that may develop due to this disease
in the early period after infection.
