SHM Converge Scientific Abstract ePoster Gallery-Diagnostic Complexity in Varicella Zoster Virus Retinitis: A Case of Subacute Vision Loss

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This case highlights a rare, diagnostically challenging presentation of varicella zoster virus (VZV) retinitis in a 47-year-old immunocompetent woman with progressive left eye vision loss. Although VZV retinitis usually presents as acute retinal necrosis with rapid retinal inflammation, necrosis, retinal detachment, and severe vision loss over days, this patient’s course was unusually subacute, developing over weeks to months and without the classic shingles rash, eye pain, headache, confusion, or other CNS symptoms.<br /><br />Her initial evaluation was broad because the clinical picture was unclear. Given her history of spontaneous coronary artery dissection and a new cerebral infarct, vasculitis, embolic/thrombotic disease, infection, and rheumatologic disorders were all considered. Work-up was largely unrevealing: infectious tests were negative for HIV, CMV, HSV, Lyme, syphilis, hepatitis B/C, and rheumatologic and hypercoagulability studies were negative. MRI of the brain and orbits showed optic nerve enhancement, a subacute infarct, and scattered leptomeningeal enhancement. Although Quantiferon-TB was positive twice, chest imaging was normal.<br /><br />The diagnosis was ultimately supported by ocular fluid testing, with vitreous PCR positive for VZV on day 1, and CSF VZV PCR also positive on day 5. She was treated promptly with intravitreal foscarnet and discharged on 14 days of IV acyclovir.<br /><br />The key teaching point is that VZV retinitis can occur in immunocompetent patients, even without rash, and may follow an indolent course. CSF testing is often negative, especially in immunocompetent individuals; ocular fluid PCR and clinical examination remain the diagnostic gold standard. This case suggests that occult VZV meningoencephalitis may precede retinal disease, and clinicians should maintain high suspicion to avoid delayed treatment and permanent vision loss.

Asset Subtitle

Matthew S. Planchon

Meta Tag

Author List Matthew S. Planchon, Patrick Kukulich

Category Clinical Vignettes

Concept Varicella Zoster Virus Retinitis

Concept Acute Retinal Necrosis

Concept Vision Loss

Concept Ocular Fluid PCR

Concept Antiviral Therapy

Distinguished Non-Finalist

Presenter Organization SKMC at Thomas Jefferson University

Presenting Author Matthew S. Planchon

Track Adult

Keywords

varicella zoster virus

VZV retinitis

immunocompetent

vision loss

acute retinal necrosis

vitreous PCR

CSF PCR

foscarnet

acyclovir

meningoencephalitis

Varicella Zoster Virus Retinitis

Acute Retinal Necrosis

Vision Loss

Ocular Fluid PCR

Antiviral Therapy