Necrotizing retinitis of multifactorial etiology.

Introduction. We present the case of a 73-year-old woman with osteoporosis, who presented to the emergency room with a sudden vision loss and ocular pain in the right eye, which appeared two days before. The patient mentioned loss of appetite, weight loss for three months and low fever for two weeks. Materials and methods. Among the ophthalmological findings, the most important were panuveitis, and large confluent necrotic areas in the peripheral retina. The patient was diagnosed with RE Panuveitis and acute necrotizing retinitis. Results. Blood exams showed leukocytosis and monocytosis, thrombocytosis and anemia. Further investigations showed high levels of Cytomegalovirus (CMV) anti IgG and Herpes Simplex (HS) type 1 virus anti IgM, urinary infection, and secondary hepatic cytolysis. The CT and MRI of the thorax and abdomen showed no sign of neoplastic disease, and no explanation for the CMV infection was found. The patient received general corticotherapy and antiviral therapy, and, after one month, RE BCVA was 20/ 30. Particularity of the case. Acute necrotizing retinitis in an old patient with CMV and HSV type 1, associated with secondary hepatic cytolysis, without any other immunosuppressive disease and very good outcome.


Introduction
We present the case of a 73-year-old woman with osteoporosis, who presented to the emergency room with sudden vision loss and ocular pain in the right eye, two days before. The patient mentioned loss of appetite and weight loss for three months and low fever for two weeks. The personal medical history of the patient showed no significant general or ocular pathology.

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Slit lamp examination of the right eye revealed perikeratic injection, posterior synechiae at 180 degrees inferiorly which deformed the pupil, endothelial keratic precipitates in a triangular pattern, flare in the anterior chamber and Tyndall ++.
The eye fundus showed vitreal floaters and vitritis (Fig. 1), slightly blurred margins of the optic nerve (unclear due to the inflammation or the vitreal flare), macula with absent foveal reflex, very narrow blood vessels, phantom vessels especially in peripheral retina, perivascular cuffing (vasculitic aspect) (Fig. 2), large cotton-wool spots and rare hemorrhages on the retinal periphery (Fig. 3), and, most important, large confluent necrotic areas in the periphery and mid-periphery of the retina (Fig.  2,4). The left eye had a normal aspect (Fig. 5).  The final diagnosis set was RE Necrotizing retinitis.

Discussion
Acute necrotizing retinitis (ARN) and Progressive Outer Retinal Necrosis (PORN) represent a spectrum of rapidly progressing necrotizing herpetic retinopathies. ARN usually strikes in immunocompetent hosts and continues with vasculitis, iridocyclitis, and vitritis. On the other hand, PORN occurs in immunocompromised persons due to HIV infection or other immunosuppressive conditions. These patients develop a necrotizing retinitis that may rapidly involve the macula as well as the peripheral retina, without significant intraocular inflammation or vasculopathy. The outcomes in both these entities can be devastating and include blindness from complicated retinal detachment and optic atrophy [1,2].
Clinical eye fundus aspect of necrotizing retinitis includes: -Vitritis (that can be severe); -Disk edema and retrobulbar optic nerve disease are not uncommon early in the course of ARN; -Single/ multiple areas of retinal necrosis with distinct borders; -Necrotic foci in peripheral retina; -Extension/ coalescence of foci of retina; necrosis in a circumferential fashion; -Occlusive vasculopathy with arteriolar involvement (retinal vasculitis is common, usually, primarily we could have arteritis); -Prominent anterior chamber and vitreous inflammation; -Characteristics that support but are not required for the diagnosis: • optic neuropathy or atrophy, scleritis, • ocular pain -Inflammation in the anterior and posterior segments [1,3]; -Anterior granulomatous or non granulomatous uveitis with keratic precipitates; -ARN may also present with diffuse scleritis; -Therefore, it is imperative to perform a dilated fundoscopic examination of every patient with scleritis [2,3].
A differential diagnosis is made with several infectious and noninfectious entities, most of these conditions (with the exception of Behcet disease, atypical toxoplasmosis, and bacterial endophthalmitis) progressing at a much slower pace than ARN.