Optic neuritis due to immunobiologics: first Brazilian case report
A female, 62-year-old patient, white, widow, retired housekeeper, originally from\nPresidente Prudente - SP was under treatment for psoriasis vulgaris in plaques, which\nhad started 9 years ago. She was hypertensive, a condition controlled with the daily use\nof captopril. She used low potency corticosteroids and topic moisturizers, acitretin and\nmethotrexate orally, but there was no response to these treatments. The use of\nimmunobiologics was subsequentely prescribed. No Psoriasis Area and Severity\nIndex (PASI) or the Life Quality Index reports were available. Previous\nroutine exams (PPD, chest radiography, complete blood count, biochemical profile and\nliver enzymes) did not show alterations. Live virus vaccination was not advised. Three\nintravenous infusions of diluted infliximab, at 5mg/kg, were applied in 3 hours and\nrepeated 2 and 6 weeks later. Three days after the third infusion, the patient presented\nlow visual acuity in the left eye, which required an emergency appointment with an\nophthalmologist of a private clinic in the city of Presidente Prudente. At the clinical\nexamination, lowering of visual acuity (counting of fingers at 3 meters) and blurring of\nperipheral region of the optic disc were noticed during fundoscopy. Optic neuritis was\nthen hypothesized and she was submitted to retinography. The findings confirmed the\nproposed hypothesis (). The patient was\nreferred to the emergency ophthalmologic center at the Regional Hospital of Presidente\nPrudente - SP, where the same findings were confirmed. Immediate hospitalization was\ndecided and pulse therapy started with intravenous methylprednisolone, without previous\nprescription of oral corticosteroids. Head tomography was done to rule out other causes,\nsuch as tumors and cerebrovascular accident, with normal results (). To better evaluate the optic nerve and exclude other\nsources of demyelination (common in multiple sclerosis cases), a head MRI was performed,\nwhich found a hypersignal of the left optic nerve in comparison with the right optic\nnerve in T2. This supported the diagnostic hypothesis of optic neuritis in the left eye\n(). To objectively translate the sight\nalterations felt by the patient, a visual campimetry was performed, which showed a\nnormal visual field for the right eye and alterations in the left eye: dense cecocentral\nabsolute scotoma, with relative augmentation with smaller targets (). The central target only presented an island of peripheral\nvision, localized on the lower hemifield. The computerized visual field exam, central\n30-2 threshold test revealed the following: Right eye: average sensitivity of visual\nfield normal for this age bracket. Left eye: (MD = -1.49 dB) > blind spot with\nrelative growth. CPSD = 2.46 dB, P< 10%, indicating there is a localized defect which\noccurs in less than 10% of the normal population. The collaboration of the patient was\nreasonably good. Variations in answers in 10 standard sites studied were normal\n(SF=1.91dB). After 3 years of follow-up, there was no improvement of the patient's\nvisual acuity.