Recurrent Optic Neuritis as the Only Manifestation of Chronic Hepatitis B Virus Flare

A Case Report

Diana Curras-Martin; Natasha Campbell; Attiya Haroon; Mohammad A. Hossain; Arif Asif

Disclosures

J Med Case Reports. 2018;12(316) 

In This Article

Case Presentation

A 46-year-old African American man presented with complaints of progressive, bilateral, blurring (more in his right eye than his left) for the past 5 days. Our patient did not report a history of a prior similar episode. He denied the presence of any associated pain, trauma to his eye, redness of eye, headache, dizziness, weakness/paresthesia, changes in hearing, fever, chills, weight changes, recent travel, insect or tick bite, or sick contact. His past medical history was relevant for hepatitis B virus (HBV) diagnosed 5 years ago, and his past family history was noncontributory.

Clinical Findings

His vital signs on presentation revealed a blood pressure of 132/59 mmHg, heart rate of 72 beats/min, respiratory rate of 18/min, oxygen saturation of 100% at room air, and a temperature of 98.6 °F. On physical examination, our patient was in no apparent distress, awake, alert, and oriented to person, place, and time. He was icteric with palpable nontender hepatomegaly. Heart and lung examinations were unremarkable. A neurological examination revealed significantly reduced visual fields in both eyes with normal pupillary size and reaction, however, a funduscopic examination was unremarkable. His extraocular eye movements were intact without ptosis. Other neurological examinations were normal including motor, sensory, and cranial nerves.

Timeline

Laboratory values from his first admission, second admission, and follow-up at 6 months were analyzed. On biochemistry, his electrolytes were within normal limits on all three occasions. Transaminase levels were markedly elevated on both the first and second admissions ranging from 500 to 1600 IU/L for aspartate aminotransferase (AST) and from 400 to 1500 IU/L for alanine aminotransferase (ALT). At the time of his 6-month follow-up, his AST and ALT levels were 51 and 87 IU/L respectively. Similarly, both his international normalized ratio (INR) and total bilirubin had improved to a normal range at follow-up. On complete blood count, his platelets remained stable on all three visits ranging from 127 to 210 kU/L. On both the first and second admissions, our patient was found to have positive hepatitis B envelope antigen, which was negative at the 6-month follow-up. Also, the hepatitis B virus deoxyribonucleic acid (DNA) load had markedly decreased from an average of 150 million IU/mL to 5000 IU/mL. Otherwise, his hepatitis B core immunoglobulin M (IgM), surface antibody and antigen, and hepatitis B virus envelope antibody remained unchanged.

Diagnostic Assessment

A presumptive diagnosis of optic neuritis was made and a differential diagnosis included multiple sclerosis and infectious etiology. The laboratory data are summarized above. Other serology test results, including for hepatitis C virus (HCV), hepatitis A virus (HAV), human immunodeficiency virus (HIV), syphilis, babesia and Lyme disease, were negative. A magnetic resonance imaging scan (MRI), with and without gadolinium, of his brain, orbits, neck, and spine were unremarkable. A lumbar puncture was performed considering multiple sclerosis in the differential diagnosis; cerebrospinal fluid (CSF) cytology was negative for infection and malignant cells, but showed few mature lymphocytes admixed with monocytes. CSF isoelectric focusing/immunofixation demonstrated identical bands in the CSF, consistent with a systemic, no intrathecal immune reaction, and was considered to be a negative result for oligoclonal bands. His albumin CSF level was 25 mg/dL, albumin index 6.3, and CSF IgG/albumin ratio 0.26. A diagnosis of retrobulbar optic neuritis was made in association with an HBV flare.

Therapeutic Intervention

During the first admission, our patient was started on prednisone 1 mg/kg/daily for 14 days and entecavir 1 mg/daily long-term therapy.

Follow-up and Outcomes

After few days of steroids, his blurring of vision completely resolved. He was discharged home with follow-up appointments as an outpatient. After 12 months, he presented with similar complaints after stopping his antiviral medication for 2 months. A presumptive diagnosis of optic neuritis associated with acute on chronic HBV was made. Because he had a flare of his viral hepatitis (with an AST level of 1558 IU/L and ALT level of 1488 IU/L), steroid therapy was avoided, and he was treated with entecavir alone. Our patient's visual acuity improved after 5 days of entecavir (1 mg once daily) therapy. His abdominal tenderness resolved, liver enzymes improved, and his INR returned to baseline level.

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