Acute viral maculopathy linked with hand, foot, and mouth disease

A 29-year-old white male was referred with recent onset central vision loss in the right eye for one week. The patient noticed the symptoms while suffering from fever secondary to hand, foot, and mouth disease. 

Other medical and past ocular history was unremarkable other than contact lens wear for myopia.

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Examination findings

Best-corrected visual acuity was 20/400 in the right eye and 20/30 in the left eye.

Intraocular pressures were measured at 13 mm Hg in the right eye and 11 mm Hg in the left eye.

Pupillary testing, ocular movements, confrontation visual fields, and anterior segment findings were all unremarkable.

Fundus exam of the right eye was remarkable for macular pigment mottling with all other structures being normal. The left eye exhibited a normal fundus exam. 

Fundus autofluorescence (FAF) (see Figure 1) shows a circular area of mottled pigmentation surrounding the fovea, while the left eye was normal. 

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Optical coherence tomography (OCT) was remarkable for alteration of the outer retina. Note the changes in the retinal pigment epithelium (RPE) and photoreceptor region in an approximately 3000 µm radius around the fovea (see Figure 2).

This patient has suffered acute viral maculopathy in the right eye.

Discussion

Hand, foot, and mouth (HFM) disease is a condition caused by an enteroviruses most commonly coxsackievirus A16.¹ HFM affects humans and should not be confused for foot-and-mouth (or hoof-and-mouth disease), which affects cloven-hoofed animals such as pigs and cows and is not a human disease.

The virus is usually spread by sneezing and coughing by the carrier or through oral secretions or blister fluid. Although most affected are young children, adults can be afflicted by the disease.

Typical symptoms include:

• Fever

• Sore throat

• Malaise

• Loss of appetite

• Painful oral cavity blisters

• Red rash without itching affecting palm of the hand, sole of the foot, and sometimes buttocks

Systemic complications include viral meningitis and encephalitis.

There is no specific therapy other than supportive treatment of symptoms.^1,2

Acute viral maculopathy has been reported associated with HFM. In most cases, the condition is unilateral. 

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Initially, a circular area of mild gray discoloration of the macula may be noted followed by granular hyperpigmentation of the retinal pigment epithelium. The condition may present in one or both eyes. 

There is no recommended treatment for HFM itself, and the condition is self-limiting.¹

The use of systemic corticosteroids is controversial;^3,4 however, Agrawal et al reported visual improvement in their presented case.⁴

Steroid therapy was not considered in this case because the patient had presented well beyond the acute phase of the disease with the expected outcome of profound vision loss.

References

1. Mayo Clinic. Hand-foot-and-mouth disease. Available at: http://www.mayoclinic.org/diseases-conditions/hand-foot-and-mouth-disease/basics/definition/con-20032747. Accessed 4/10/17.

2. Centers for Disease Control and Prevention. Hand, Foot, and Mouth Disease (HFMD). Available at: www.cdc.gov/hand-foot-mouth. Accessed 4/10/17.

3. Haamann P, Kessel L, Larsen M. Monofocal outer retinitis associated with hand, foot, and mouth disease caused by coxsackievirus. Am J Ophthalmol. 2000 Apr;129(4):552-3.

4. Agrawal R,  Bhan K,  Balaggan K, Lee RW, Pavesio CE, Addison PK. Unilateral acute maculopathy associated with adult onset hand, foot and mouth disease: case report and review of literature. J Ophthalmic Inflamm Infect. 2015 Feb 1;5:2.

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