case report unilateral optic neuritis: a rare complication...

Case ReportUnilateral Optic Neuritis A Rare Complication afterMeasles-Mumps-Rubella Vaccination in a 30-Year-Old Woman

Chiara De Giacinto Elvira Guaglione Pia E Leon Rossella DrsquoAloisio Odilla VattovaniGiuseppe Ravalico and Daniele Tognetto

University Eye Clinic of Trieste Ospedale Maggiore Piazza dellrsquoOspitale 1 34125 Trieste Italy

Correspondence should be addressed to Chiara De Giacinto chiaradegiacintogmailcom

Received 31 December 2015 Accepted 30 March 2016

Academic Editor J Fernando Arevalo

Copyright copy 2016 Chiara De Giacinto et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Purpose To report a case of unilateral optic neuritis following Measles-Mumps-Rubella (MMR) vaccinationMethods A 30-year-old female developed unilateral optic neuritis five days after a Measles-Mumps-Rubella (MMR) booster vaccination The patientdisplayed unilateral involvement with severe visual lossHowever visual acuity improved significantly after four days of intravenoussteroid therapy with 500mgday of methylprednisoloneConclusions Optic neuritis is one of the rare complications associated withthemumps measles and rubella vaccine It may be a toxic reaction to the nonviral component of the vaccine but the exact etiologyis unknown Postvaccination neuritis is generally bilateral and usually affects children In adults unilateral optic neuritis is usuallycorrelated with multiple sclerosis (MS)

1 Introduction

Optic neuritis is an inflammatory infectious or demyelinat-ing disorder affecting the optic nerve Bilateral optic neuritisusually affects children and often follows viral infectionswhile it rarely affects adult patients not suffering from sys-temic inflammatory or autoimmune disease In adults opticneuritis is typically unilateral and is correlated with multiplesclerosis (MS) [1]

In rare cases optic neuritis may develop after vaccina-tion injections Postvaccination neuritis is generally bilateraland only rarely unilateral The medical literature includescases of optic neuritis developing after vaccinations fortuberculosis hepatitis B rabies tetanus meningitis anthraxmumps measles and rubella [1] The influenza vaccine isalso associated with a higher incidence of optic neuritis [1]Optic neuritis following MMR vaccination usually developsbetween one week and a maximum of one month afteradministration of the vaccine [2ndash6] However a case of apatient who experienced a worsening vision as soon as only24 hours after vaccination has been recorded [7]

2 Case Presentation

A healthy 30-year-old woman complained of headache andfever two days after administration of the MMR vaccineAbout five days later the patient reported a unilateral blurringof vision She underwent a full ophthalmologic examinationat the emergency department of the Ophthalmology Clinicin Trieste General Hospital Visual acuity was found to be2020 in both eyes and the slit-lamp examination showed ananterior segment without signs of inflammation Intraocularpressure was 14mmHg in both eyes On fundus examinationof the right eye the optic disc appeared to be normal whereasthe left eye optic disc margin was blurred FluoresceinAngiography (FA) of the left eye showed the edges of theoptical disc to be blurred revealing the early stages ofhyperfluorescenceTherewas no other angiographic evidenceof disease in the left eye Moreover the right eye was withinthe normal angiographic range Two color photographs of thefundus were taken confirming the presence of optic nervehead edema

On the third day after the first examination visual acuitywas found to be 20100 BCVA The patient was treated with

Hindawi Publishing CorporationCase Reports in Ophthalmological MedicineVolume 2016 Article ID 8740264 3 pageshttpdxdoiorg10115520168740264

2 Case Reports in Ophthalmological Medicine

30

(a)

quad

30

(b)

30

(c)

Figure 1 Visual field (a) In acute phase (b) After 5 days from treatment (c) After 40 days from treatment

Table 1 Visual Evoked Potentials (VEP) in acute phase

VEP pattern 601015840 VEP pattern 151015840

Amplitude (uV) 293 242Latency (ms) 10957 10957

500mg iv of methylprednisolone for four days The Com-puterized Perimetry Test (Figure 1(a)) revealed an overallreduction in the visual field Electrophysiological exams wereperformed the Visual Evoked Potentials (VEP) showed anincreased latency and a reduction in amplitude (Table 1)

Additional radiological investigations were deemed nec-essary a CT head scan with and without contrast mediumand magnetic resonance imaging (MRI) of the brain withand without contrast medium Following administration of

the contrast medium the CT scan disclosed a nonhemor-rhagic ultradense lesion with no signs of focal encephalitisinjuries The MRI revealed minor thickening of the left opticnerve corresponding to an increased intensity of the T2signal within a framework involving hyperemia and edema

Four days of infusion therapy was followed by ten daysof oral corticosteroid therapy with a gradually diminishingdosage Visual acuity remained stable at 20100 BCVA for thenext five days and was followed by a gradual improvement invisual acuityThe Computerized Perimetry Test was repeated(Figure 1(b)) and showed a significant improvement Ascotoma remained in a peripheral superonasal position inthe left eye After forty days visual acuity was found tobe 2020 BCVA and the visual field was within normallimits (Figure 1(c)) Electrophysiological exams revealed animprovement with a lower VEP latency and an increasedamplitude (Table 2)

Case Reports in Ophthalmological Medicine 3

Table 2 Visual Evoked Potentials (VEP) after 40 days fromtreatment



3 Discussion

The Measles-Mumps-Rubella vaccine consists of MMR andlive attenuated virus prepared in baby chick embryo cellcultures

Adverse events associated with theMMR vaccination canvary from simple local pain to rare systemic disorders suchas anaphylactic shock Over the last thirty years six cases ofoptic neuritis following vaccination against measles mumpsand rubella have been reported

Kazarian and Gager [2] reported the case of a 6-year-old boy who developed bilateral optic neuritis only 18 daysafter administration of the trivalent vaccine Kline et al[3] described a case of a 31-year-old woman who devel-oped bilateral optic neuritis 11 days after a vaccination forrubella Riikonen [4] diagnosed a unilateral optic neuritisand subsequent multiple sclerosis four weeks after rubellavaccination Stevenson et al [5] reported two cases bothinvolving 13-year-olds who developed optic neuritis 2-3weeks after vaccination for measles and rubella Arshi et al[7] described a case of rapid onset optic neuritis in whichthe complication came out just in few hours in a 16-year-oldboy and Moradian and Ahmadieh [6] reported two cases ofoptic neuritis with onset less than 24 hours followingmeasles-rubella vaccination

To the best of our knowledge there are no papers inthe literature describing a case of unilateral optic neuritisfollowing MMR vaccination in an adult without known sys-temic inflammatory or autoimmune disorders Our patientdeveloped optic neuritis about five days after being givena dose of MMR vaccine As in the cases described in theliterature above neurological complications occurred withina week to one month of the administration of the MMRvaccine long enough to increase the antibody titer andantigen-antibody complexes Damage was due to immunecomplex disease which caused vascular lesions and led tohyperemia and perivascular inflammation with consequentrupture of the blood-brain barrier [4 5] An etiopathogeneticmechanism is consistent with the foregoing condition

Optic neuritis is one of the rare complications associatedwith the mumps measles and rubella vaccine This neu-rological disorder may be a toxic reaction to the nonviralcomponent of the vaccine [4] and is probably caused bythe antibody titer against live attenuated virus It should bestressed that this is a temporary clinical situation whichresolves after administration of a high dose of corticosteroidin the initial phase of the therapy However it can lead to bothunilateral and bilateral optic neuritis and can affect both sexesand all ages in subjects who undergo vaccination

Another purpose of this case report is to underlinethe importance of assessing a patientrsquos medical history and

establishing the correlation between clinical symptoms andthe MMR vaccine not least because vaccination campaignsare recognized and supported by the WHO (World HealthOrganization) throughout the world

Competing Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

Acknowledgments

The authors thank Roberta Marchesan (neurophysiopathol-ogy technician) and Patrizia Bigarella (graphic technician) ofthe University Eye Clinic of Trieste for the support

References

[1] J P Stubgen ldquoA literature review on optic neuritis followingvaccination against virus infectionsrdquo Autoimmunity Reviewsvol 12 no 10 pp 990ndash997 2013

[2] E L Kazarian and W E Gager ldquoOptic neuritis complicatingmeasles mumps and rubella vaccinationrdquo American Journal ofOphthalmology vol 86 no 4 pp 544ndash547 1978

[3] L B Kline S L Margulies and S J Oh ldquoOptic neuritis andmyelitis following rubella vaccinationrdquo Archives of Neurologyvol 39 no 7 pp 443ndash444 1982

[4] R Riikonen ldquoThe role of infection and vaccination in thegenesis of optic neuritis andmultiple sclerosis in childrenrdquoActaNeurologica Scandinavica vol 80 no 5 pp 425ndash431 1989

[5] V L Stevenson J F Acheson J Ball and G T Plant ldquoOpticneuritis following measlesrubella vaccination in two 13-year-old childrenrdquoThe British Journal of Ophthalmology vol 80 no12 pp 1110ndash1111 1996

[6] S Moradian and H Ahmadieh ldquoEarly onset optic neuritisfollowing measles-rubella vaccinationrdquo Journal of Ophthalmicand Vision Research vol 3 no 2 pp 118ndash122 2008

[7] S Arshi H Sadeghi-Bazargani H Ojaghi et al ldquoThe firstrapid onset optic neuritis aftermeasles-rubella vaccination casereportrdquo Vaccine vol 22 no 25-26 pp 3240ndash3242 2004

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2 Case Reports in Ophthalmological Medicine

30

(a)

quad

30

(b)

30

(c)

Figure 1 Visual field (a) In acute phase (b) After 5 days from treatment (c) After 40 days from treatment

Table 1 Visual Evoked Potentials (VEP) in acute phase



500mg iv of methylprednisolone for four days The Com-puterized Perimetry Test (Figure 1(a)) revealed an overallreduction in the visual field Electrophysiological exams wereperformed the Visual Evoked Potentials (VEP) showed anincreased latency and a reduction in amplitude (Table 1)

Additional radiological investigations were deemed nec-essary a CT head scan with and without contrast mediumand magnetic resonance imaging (MRI) of the brain withand without contrast medium Following administration of

the contrast medium the CT scan disclosed a nonhemor-rhagic ultradense lesion with no signs of focal encephalitisinjuries The MRI revealed minor thickening of the left opticnerve corresponding to an increased intensity of the T2signal within a framework involving hyperemia and edema

Four days of infusion therapy was followed by ten daysof oral corticosteroid therapy with a gradually diminishingdosage Visual acuity remained stable at 20100 BCVA for thenext five days and was followed by a gradual improvement invisual acuityThe Computerized Perimetry Test was repeated(Figure 1(b)) and showed a significant improvement Ascotoma remained in a peripheral superonasal position inthe left eye After forty days visual acuity was found tobe 2020 BCVA and the visual field was within normallimits (Figure 1(c)) Electrophysiological exams revealed animprovement with a lower VEP latency and an increasedamplitude (Table 2)





3 Discussion








Competing Interests


Acknowledgments


References













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ObesityJournal of




















3 Discussion








Competing Interests


Acknowledgments


References













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Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















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OncologyJournal of





PPAR Research



Journal of

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case report unilateral optic neuritis: a rare complication...

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