Mycophenolate-mofetil/tacrolimus/unspecified steroids
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Varicella zoster infection resulting in acute retinal necrosis: case report A 24‑year‑old man developed varicella zoster infection resulting in acute retinal necrosis (ARN) following immunosuppression therapy with mycophenolate-mofetil, tacrolimus and unspecified steroids. The man, who had undergone renal transplant, started receiving immunosuppression therapy with tacrolimus, mycophenolate mofetil and unspecified steroid [dosages and routes not stated]. Two months after the transplant, he presented to the hospital due to cutaneous varicella infection. Anamnesis showed he had a past history of disseminated tuberculosis in July 2016, that had resolved after antitubercular therapy. He also had a history of mediastinal lymphadenopathy and end‑stage renal disease that required haemodialysis. His varicella infection resolved after one week. However, 2 weeks later, he reported acute onset of blurred vision bilaterally. His right eye visual acuity was 6/36 and the left eye visual acuity was 3/60. His ocular examination was suggestive of anterior uveitis in the left eye along with keratic precipitates in the left-sided anterior chamber and several choroiditic patches. There was no evidence of retinitis or ARN was observed in his both the eyes. MRI of the brain failed to reveal any intracranial pathology. Therefore, he was treated with atropine and prednisolone for left anterior uveitis that led to improvement in left eye visual acuity. But, he had deterioration of right eye visual acuity to 6/60 in January 2019. Subsequently, he again had flare up of anterior uveitis and his right eye vision further worsened to 2/60 along with keratic precipitates, 3+ cells, whereas the left eye visual acuity remained constant at 6/60. Three weeks later, deterioration of vision was noted on finger counting at 1 meter in right eye with 3+ cells. He also had 1+ flare and ARN in the right eye. Because of recent varicella infection, the man was preemptively treated with aciclovir [acyclovir] and supportive therapy. Photocoagulation was performed and the dose of immunosuppression therapy was reduced. A subsequent improvement in his right eye vision was noted with resolution of the acute retinal necrosis. His PCR of sample form right aqueous humor showed positive result for varicella‑zoster virus DNA. Therefore, acyclovir was given for 6 weeks that led to gradual improvement in his eye. Thereafter, his visual acuities were 6/60 and 6/6 in the right eye and in the lest eye, respectively. A stable graft function was noted while on triple‑drug immunosuppression therapy (mycophenolate-mofetil, tacrolimus and unspecified steroids). The immunosuppression therapy (mycophenolate-mofetil, tacrolimus and unspecified steroids) was considered to be a risk factor for the varicella zoster virus infection and it’s dissemination, which further resulted in ARN [durations of treatments to reactions onsets not stated]. Prakash S, et al. Perplexing etiology of acute retinal necrosis in a renal transplant recipient. Indian Journal
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