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A 79 year old man with visual changes
Digital Journal of Ophthalmology 2005
Volume 11, Number 9
April 7, 2005
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Burton Goldstein, M.D. | University of South Florida
William Mcdowell, M.D. | Uiversity of South Florida
Diagnosis and Discussion
The patient was diagnosed with West Nile encephalitis. The organism responsible, the West Nile virus, is a flavivirus found in humans, birds and other vertebrates. Human cases of West Nile Virus infection in the United States for 2003 totaled 9,862 (1). The virus in now established in the western hemisphere and requires consideration in the differential diagnosis of choroiditis.

Infection is usually asymptomatic but in approximately 20% of the people infected, symptoms can develop including fever, headache, fatigue, myalgias, and occasionally a skin rash on the trunk of the body. Severe infection can cause a meningitis or encephalitis picture. (2) Ocular symptoms usually begin shortly after systemic symptoms. Vision usually returns to baseline within weeks. There is no known effective treatment for systemic or ocular disease.

While the infectious etiology had been identified prior to this patient’s presentation, it is likely many patients go undiagnosed. West Nile associated choroiditis is a potential complication of viral infection that can aid in the recognition of this condition.

The ophthalmic findings in this case were consistent with several previously described cases of West Nile choroiditis. (3-7). Similar bilateral, chorioretinal, variable-sized lesions have been described in several of these reports. Findings of bilateral targetoid lesions (i.e.: hyperpigmentation surrounded by hypopigmentation) and linear hypopigmented streaks appear to be characteristic. Circular lesions range from 300-1000 microns in size and can slowly enlarge. The streak chorioretinal lesions range from 200-1500 microns in size and begin cream colored and become hypopigmented. (8) Targetoid lesions appear to be the resolving stage of initially cream-colored circular lesions, which will eventually atrophy.
Other case reports have described additional signs of West Nile ocular involvement include conjunctival hyperemia, non-granulomatous keratic precipitates, anterior chamber reaction, and occlusive retinal vasculitis, which were not found in this patient. There was no overlying retinitis, vasculitis or neurosensory detachment. It has been reported that elderly and diabetic patients are more prone to the neurologic sequelae of West Nile virus infections. (9)

This patient presented with a documented case of West Nile virus infection that made the diagnosis of coincident West Nile virus choroiditis evident. However, it demonstrates the need to include such infection in the differential diagnosis of choroiditis