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


J Med Case Reports. 2018;12(316) 

In This Article


Worldwide, 240 million individuals are estimated to have chronic HBV infection. The incidence of HBV in USA is 21,900 annually and approximately 5% of adults become chronically infected.[3] The detection of serum HB surface antigen for more than 6 months is considered to be diagnostic of chronic HBV infection, whereas the decision to treat is based upon the presence of HBe antigen, ALT, and the HBV DNA viral load. Several extrahepatic manifestations are associated with chronic HBV infection, such as arthralgia, vasculitis, neuritis, and membranous and membranoproliferative glomerulonephritis. While our patient had HBV flare with resultant elevation of his AST and ALT levels, his visual abnormality was the only extrahepatic manifestation encountered. With entecavir therapy, the ocular manifestation resolved and his liver function normalized.

Optic neuritis is the primary inflammation of the optic nerve and is often referred to as retrobulbar optic neuritis.[4,5] Approximately, two thirds of cases demonstrate a normal optic disc on funduscopic examination, while others may demonstrate blurring of the disc. The case presented in this report revealed a normal disc on funduscopic examination, which consequently did not assist us in making the diagnosis. Post-viral optic neuritis usually precedes the infection by 1–3 weeks. Several additional viruses have been associated with this phenomenon including Epstein-Barr, measles, mumps, influenza, and varicella-zoster virus.[6] The use of methylprednisolone 1 mg/kg/daily for 14 days hastens recovery, and is considered a reasonable option according to current guidelines.[7,8] However, we could not use steroid therapy due to the acute flare of HBV in our patient.

Post-hepatitis B infection polyneuropathy in adults and optic neuritis associated with hepatitis B vaccination, mainly in children, have been reported frequently in the medical literature; however, there are only two cases of post-infectious retrobulbar optic neuritis associated with HBV infection reported in the medical literature so far.[9–11] The first case, a post-infectious acute HBV optic neuritis was described by Galli et al. at the University of Milan in 1986.[9] The patient (a young woman) reported decreased visual acuity after normalization of liver enzymes that remitted after a course of steroids.[9] The second case was reported by Achiron et al. at (Emory University School of Medicine, Atlanta in 1994) a middle-aged woman who developed painful loss of vision and fatigue 1 month after her acute HBV infection subsided. Further investigation of this case revealed the presence of papilledema during the ophthalmologic examination and was associated with glomerulonephritis and arthritis. Ocular symptoms significantly improved after 1 week of steroids.[10]

In our case, the initial presentation was treated with steroids at the standard dose of methylprednisolone (1 mg/kg/daily) for 14 days with good response. The steroid use in the two previously reported patients occurred in the setting of post-viral optic neuritis, whereas the presence of severe active infection during our patient's second admission constituted a relative contraindication to steroid therapy. However, our patient responded well to the re-initiation of his antiviral regimen without any steroid use.

The most likely pathophysiological mechanism governing this presentation is an elevated number of immune-complex depositions and subsequent complement cascade activation.[12] It has been reported that aggressive forms of chronic hepatitis B virus are characterized by a higher frequency of circulating immune complexes along with higher anti-HBs antibodies,[13] increasing the possibilities of immune-related events such as the optic neuritis observed in our patient.