ABSTRACT

Arboviral diseases such as Zika, dengue fever, and chikungunya are considered as current public health problems in Brazil, taking into account the high number of travelers and the population living in endemic areas. Acute neurological manifestations have been described, including ophthalmological changes. In the present report, we describe the case of a 37-year-old patient living in the city of Rio de Janeiro who presented with fever and developed Guillain-Barré syndrome thereafter, confirmed by chikungunya serology and associated with ophthalmoplegia. Given the situation of epidemic in recent years, these viral diseases should be considered in the differential diagnosis of any fever with neurological and/or ophthalmological manifestations, especially in endemic areas.

Keywords: Ophthalmoplegia; Guillain-Barre Syndrome; Chikungunya vírus.

RESUMO

As arboviroses como Zika, Dengue e Chikungunya são consideradas problemas públicos de saúde atual no Brasil, considerando o elevado número de viajantes e a população que vive nas áreas endêmicas. Já foram descritas com manifestações neurológicas agudas, incluindo alterações oftalmológicas. Neste relato, descrevemos o caso de um paciente de 37 anos, morador da cidade do Rio de Janeiro, que após um quadro febril, desenvolveu síndrome de Guillain-Barré confirmada por sorologia com Chikungunya associada com oftalmoplegia. Diante do quadro de epidemia dos últimos anos, qualquer quadro febril com manifestação neurológica e/ou oftalmológica deve ser considerado como diagnóstico diferencial para esses vírus, especialmente em áreas endêmicas.

Palavras-chave: Oftalmoplegia; Síndrome de Guillain-Barré; Vírus Chikungunya.

RESUMEN

Las arbovirosis como Zika, Dengue y Chikungunya actualmente se consideran problemas públicos de salud en Brasil, si se considera el elevado número de viajantes y la población que vive en las áreas endémicas. Ya se describieron con manifestaciones neurológicas agudas, incluyéndose cambios oftalmológicos. En este reporte, describimos el caso de un paciente de 37 años, que vive en la ciudad de Rio de Janeiro, el que, tras presentar síntomas de fiebre, desarrolló el síndrome de Guillain-Barré, lo que se confirmó por sorología con Chikungunya asociada con oftalmoplejía. Delante del cuadro de epidemia de los últimos anos, cualquier cuadro de fiebre con manifestación neurológica y/o oftalmológica debe considerarse como diagnóstico diferencial para esos virus, sobretodo en áreas endémicas.

Palabras-clave: Oftalmoplejía; Síndrome de Guillain-Barré; Virus Chikungunya.

INTRODUCTION

Arboviral diseases have emerged in different parts of the world because of the diversity in viral genetic variants, changes in host and vector populations, or anthropogenic environmental factors¹. The chikungunya virus is an RNA arbovirus that typically causes fever and arthralgia after an incubation period of 2–10 days², with an increasing prevalence of neurological findings^3,4,5. Its vectors are the mosquitoes Aedes aegypti and Aedes albopictus. Infection from this virus may cause several ocular manifestations, including conjunctivitis, uveitis, vitreitis, choroiditis, neuritis, and ophthalmoplegia^6,7,8. The latter can occur both in Guillain–Barré syndrome and in its variant, Miller Fisher syndrome, but this is remains to be elucidated⁹. The classic Miller Fisher syndrome triad is ophthalmoplegia, ataxia, and areflexia¹⁰.

In this report, we present the case of a 37-year-old patient from the city of Rio de Janeiro who, after having fever, developed Guillain–Barré syndrome associated with ophthalmoplegia and was diagnosed on the basis of positive chikungunya serology.

CASE REPORT

A 37-year-old male patient, living in the city of Rio de Janeiro, was hospitalized in the Medical Unit due to lower limb paraparesis and based on the diagnosis of Guillain-Barré syndrome. From the moment of admission, he complained of low visual acuity in both eyes and bilateral limited ocular motility. On eye examination, the patient denied diplopia or eye pain and showed 20/20 best-corrected visual acuity in both eyes. Anterior segment biomicroscopy and posterior segment funduscopic examination showed no changes. Extraocular muscle function testing showed bilateral ptosis, which was more evident in the left eye than the right one in the primary gaze position (Figure 1); preserved direct and consensual pupillary light reflexes; unchanged accommodation and convergence; the absence of relative afferent pupil defect; equal pupils, centered and without deviation; the absence of movements of adduction (Figure 2), abduction (Figure 3), infraduction (Figure 4), supraduction (Figure 5), infraversion, and supraversion in both eyes. Viral serology tests were requested for dengue (IgM negative), Zika (undetectable PCR), and chikungunya (non-reactive IgM and reactive IgG). The patient was jointly treated with the Neurology department and received intravenous immunoglobulin, and the lower limb paresis started to improve.

Figure 1. Primary gaze position.

Figure 2. Adduction.

Figure 3. Abduction.

Figure 4. Infraduction.

Figure 5. Supraduction.

CONCLUSION

Ophthalmoplegia manifest both in Guillain–Barré syndrome and in its variant, Miller Fisher syndrome, if limbal involvement is noted. However, ophthalmoplegia is infrequent in Guillain–Barré syndrome¹⁰. We should emphasize that this patient presented with ophthalmoplegia with the involvement of the levator palpebrae superioris muscle, unlike what Dutta and Sharma described¹¹. Acute neurological manifestations have been reported in arboviral diseases such as Zika, dengue fever, and chikungunya and can be detected by a laboratory analysis of these patients’ cerebrospinal fluid¹¹. Given the situation of epidemic in recent years, these viral diseases should be considered in the differential diagnosis of any fever with neurological and/or ophthalmologic manifestations, especially in endemic areas¹². This represents a challenge to worldwide public health, considering the large number of travelers and the population living in endemic areas¹³. Further studies are required for improving the diagnosis of these arboviral diseases.

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Rebeca de Azevedo Souza
http://lattes.cnpq.br/1793505934218298
https://orcid.org/0000-0001-6557-0723

Thiago José Cavalcanti Valadão
http://lattes.cnpq.br/8523779372510890
https://orcid.org/0000-0001-8050-6930

Roland Bittencourt Goettenauer Neto
http://lattes.cnpq.br/2845198848467563
https://orcid.org/0000-0003-2144-6901

Received on: February 19, 2018.
Accepted on: March 15, 2018.