key: cord-0756217-xek4vxpj authors: Rahman, Effie Z.; Shah, Pooja; Ong, Jeremy E.; Goldberg, Morton; Ong, Sally S. title: Purtscher-like retinopathy in a patient with COVID-19 and disseminated intravascular coagulation date: 2021-11-11 journal: Am J Ophthalmol Case Rep DOI: 10.1016/j.ajoc.2021.101229 sha: b87b44e88d8474dd0a1b852c93827b4c95a87741 doc_id: 756217 cord_uid: xek4vxpj PURPOSE: To describe a unique case of Purtscher-like retinopathy after a severe, complicated COVID-19 course which included development of disseminated intravascular coagulation (DIC). OBSERVATIONS: A 58-year-old male developed blurry vision in the left eye one week after being discharged from the hospital for severe COVID-19 pneumonia and DIC. He had been intubated and ventilated for 5 days. Fundus examination revealed optic nerve hyperemia in the right eye, optic nerve pallor in the left eye, arteriolar attenuation, multiple cotton wool spots and ill-defined areas of retinal whitening in the posterior pole in both eyes. His exam findings were most consistent with Purtscher-like retinopathy in both eyes. CONCLUSIONS: and Importance: While several cases of central retinal artery and vein occlusions have been described in COVID-19 patients thus far, there has not been any reported cases of Purtscher-like retinopathy. To the best of our knowledge, this is the first case of Purtscher-like retinopathy in a patient who developed DIC during a severe COVID-19 infection. The emergence of SARS-CoV-2 has caused a high burden of infection-associated complications in nearly every organ system. Conjunctivitis is the main ocular consequence of COVID-19 reported, with SARS-CoV-2 RNA detected in tear and conjunctival secretions. 1, 2 Retinal manifestations have also been reported in SARS-CoV-2. A prospective cross-sectional study by Sim et al. of 216 eyes demonstrated retinal microangiopathy in 11% of patients with COVID-19 . 3 The SERPICO-19 study showed dilation of the retinal vasculature, and a positive correlation between mean vein diameter and disease severity in subjects with COVID-19. 4 In a case series of 12 patients with COVID-19, four had subtle cotton wool spots and microhemorrhages along the retinal arcades, but all retained normal visual acuity. 5 There have also been several case reports of central retinal artery [6] [7] [8] [9] and vein [10] [11] [12] [13] [14] [15] occlusion in COVID-19. One study, however, did not find any retinal complications in 46 patients with severe COVID-19 pneumonia. 16 To the best of our knowledge, this is the first case of Purtscher-like retinopathy described in a patient with severe COVID-19 pneumonia who also developed disseminated intravascular coagulation (DIC). A 58-year-old male with a past medical history of gout and chronic thrombocytopenia had seizures, lost consciousness at home and was brought to the Emergency Room via ambulance. In the preceding weeks, his wife and daughter had both tested positive for COVID-19. The patient was febrile (102.3F) and had elevated inflammatory markers including D-dimer of 4770 ng/ml, C-reactive protein of 67.6 mg/L, and leukocytosis of 13.4. A chest X-ray showed multifocal pneumonia with ground-glass opacities. The patient tested positive for COVID-19 using the Roche COBAS SARS-CoV-2 and Influenza A/B PCR test on the LIAT instrument, which is only intended for use under the FDA's J o u r n a l P r e -p r o o f Emergency Use Authorization. He was diagnosed with COVID-19 pneumonia and was intubated due to respiratory failure with hypoxia and hypercapnia. The patient's hospital course was complicated by DIC with bleeding from the nares, oropharynx, and gastrointestinal tract, secondary MRSA bacterial pneumonia, and multifactorial acute metabolic encephalopathy in the setting of respiratory failure, sepsis and decompensated alcoholic cirrhosis. His hemoglobin and hematocrit dropped from 10 g/dL and 31.7% to 6.9 g/dL and 22.1% respectively and his platelet count dropped from 37,000/uL to 32,000/uL. He also had prolonged PT and PTT at 16.6 and 36 seconds respectively. Other laboratory abnormalities included elevated procalcitonin (19.5 ng/mL), lactic acid (16.0 mmol/L), hyperammonemia (130 mcg/dL) and hyperbilirubinemia (2.9 mg/dL). Abdominal ultrasound demonstrated coarsened hepatic echotexture with a nodular capsule and trace ascites, which indicated cirrhosis. He was placed on life support for 5 days. His treatment regimen included a course of remdesivir and decadron for COVID-19 pneumonia, as well as 6 days of intravenous vancomycin for MRSA pneumonia. He was given fresh frozen plasma, platelets, and packed red blood cells for disseminated intravascular coagulation as well as lactulose and rifaximin for hepatic encephalopathy. He reported an alcohol intake of 12 standard drinks per week and was evaluated by gastroenterology. However, since he had no abdominal pain, nausea or vomiting, serum amylase and lipase were not checked. He was discharged after 15 days of hospitalization. He noted blurry vision in the left eye one week after discharge from the hospital. One month after onset of visual symptoms, he presented to a community-based ophthalmologist with visual acuity of 20/25 in the right eye and 20/400 in the left eye, and a relative afferent pupillary defect in the left eye. 18 In addition to the retina, our patient had evidence of hypoxic insult to multiple other organ systems including the lung, liver and brain. He had white matter lesions on brain MRI, which potentially represented leukoencephalopathy and demyelination in the setting of hypoxic insults. 19 Purtscher retinopathy is classically associated with trauma, while Purtscher-like retinopathy has been associated with acute pancreatitis, renal failure, surgery, and DIC. In particular, Purtscher-like retinopathy has been reported in patients with DIC and concurrent nephrotic syndrome 18 We further confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript. IRB approval was obtained (required for studies and series of 3 or more cases) Written consent to publish potentially identifying information, such as details or the case and photographs, was obtained from the patient(s) or their legal guardian(s). The International Committee of Medical Journal Editors (ICMJE) recommends that authorship be based on the following four criteria: 1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND 2. Drafting the work or revising it critically for important intellectual content; AND 3. Final approval of the version to be published; AND 4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All those designated as authors should meet all four criteria for authorship, and all who meet the four criteria should be identified as authors. For more information on authorship, please see http://www.icmje.org/recommendations/browse/roles-andresponsibilities/defining-the-role-of-authors-and-contributors.html#two. All listed authors meet the ICMJE criteria. We attest that all authors contributed significantly to the creation of this manuscript, each having fulfilled criteria as established by the ICMJE. One or more listed authors do(es) not meet the ICMJE criteria. We believe these individuals should be listed as authors because: We confirm that the manuscript has been read and approved by all named authors. We confirm that the order of authors listed in the manuscript has been approved by all named authors. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection Ocular manifestations and clinical characteristics of 535 cases of COVID-19 in Wuhan, China: a cross-sectional study Retinal microvascular signs in COVID-19 Retinal findings in patients with COVID-19: Results from the SERPICO-19 study Retinal findings in patients with COVID-19 Simultaneous Bilateral Central Retinal Artery Occlusion following COVID-19 Infection Case Report: Central Retinal Artery Occlusion in a COVID-19 Patient Paracentral acute middle maculopathy in the setting of central retinal artery occlusion following COVID-19 diagnosis Central retinal vein occlusion in a young healthy COVID-19 patient: A case report Central retinal vein occlusion with COVID-19 infection as the presumptive etiology Bilateral Central Retinal Vein Occlusion in a 40-Year-Old Man with Severe Coronavirus Disease 2019 (COVID-19) Pneumonia. Am J Case Rep Central retinal vein occlusion in the setting of COVID-19 infection COVID-19-associated central retinal vein occlusion treated with oral aspirin Retinal involvement and ocular findings in COVID-19 pneumonia patients. Sci Rep Systematic review of Purtscher's and Purtscher-like retinopathies. Eye (Lond) Contact with the Editorial Office The Corresponding Author declared on the title page of the manuscript is: Sally S. Ong This author submitted this manuscript using his/her account in EVISE He/she is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that the email address shown below is accessible by the Corresponding Author, is the address to which Corresponding Author's EVISE account is linked, and has been configured to accept email from the editorial office of We understand that this author is the sole contact for the Editorial process (including EVISE and direct communications with the office). He/she is responsible for communicating with the other authors, including the Corresponding Author, about progress, submissions of revisions and final approval of proofs The authors gratefully thank R. Tyler Davis, DO for referring and sharing clinical information about the patient with us, and William Graham Jr. for his expertise in image acquisition. [Instructions: Please check all applicable boxes and provide additional information as requested.] Potential conflict of interest exists:We wish to draw the attention of the Editor to the following facts, which may be considered as potential conflicts of interest, and to significant financial contributions to this work:The nature of potential conflict of interest is described below:No conflict of interest exists.We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. Funding was received for this work.All of the sources of funding for the work described in this publication are acknowledged below: No funding was received for this work. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property.