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Journal of Child Neurology
J Child Neurol 2010; 25; 321
Francis J. DiMario, Jr, Mirna Hajjar and Thomas Ciesielski
A 16-Year-Old Girl With Bilateral Visual Loss and Left Hemiparesis Following an Immunization Against Human Papilloma Virus
Visual loss is a symptom that can occur from lesions anywhere along the visual pathways. Binocular visual loss can be further localized depending on
the size and location of the scotoma identified on examination. Lesions affecting the chiasm, in particular, may produce bitemporal visual field loss and the additional
involvement of the optic nerves and/or retrochiasmatic visual pathways will induce more complete degrees of blindness.
There are a multitude of etiologies that produce this latter pattern of visual loss; however, the pace of progression, the anatomic localization of the process, and the precipitating circumstances will aid in pathophysiologic classification as compressive or noncompressive. Noncompressive etiologies involving the chiasm include processes within the spectrum from acute to a more chronic temporal course.
This slower time course is characteristic of infiltrative lesions, granulomatous diseases, axonal dieback phenomenon secondary to multiple sclerosis,1 and Leber hereditary optic neuropathy. Acute noncompressive lesions of the optic chiasm have been described in infectious settings with Lyme disease,2 Epstein-Barr virus,3,4 varicella zoster virus5 and mumps,6 systemic lupus erythematosus, 7,8 and demyelinating processes (eg, neuromyelitis optica and multiple sclerosis).
Tumefactive demyelinating lesions are those defined as large (>2 cm) lesions with a surrounding zone of edema with or without accompanying mass effect. There have been a few case reports and case series in the literature where tumefactive lesions have been described in the context of both multiple
sclerosis and acute demyelinating encephalomyelitis.
However, chiasmal neuritis as part of acute demyelinating encephalomyelitis has not to our knowledge been reported in the medical literature. Although chiasmal neuritis generally tends to have a more favorable outcome with eventual return of vision over time, when it is caused by neuromyelitis optica and Leber hereditary optic neuropathy the outcomes have been poorer with sustained visual loss.
We report the case of a 16-year-old girl who suffered an acute and sustained onset of bilateral visual loss and transient left hemiparesis following an immunization against human papilloma virus, who was found to have both a tumefactive demyelinating lesion and chiasmal neuritis as part of a presentation of acute demyelinating encephalomyelitis.