Case Report: Acute Vision Loss from IgG4-Related and Bacterial Rhinosinusitis after COVID-19

Article: A COVID-19 Patient Lost Vision in One Eye. Here's How They Could Be Connected
Source: ScienceAlert
Published: August 27, 2021

Complete opacification of (A) the right frontal sinus, (B) the right ethmoid sinus
with erosion of the medial orbital apex bone,and (C) the right maxillary sinus

A recent case report involving a COVID-19 patient who experienced acute loss of vision in one eye provides insight into how SARS-CoV-2 infection could affect the immune system. Specifically, the patient was diagnosed with immunoglobulin G4-related disease (IgG4-RD) concurrent with bacterial rhinosinusitis, the first such case reported in the literature. The patient experienced complete resolution of symptoms after treatment with surgery, antibiotics, and corticosteroids; however, the unusual coinciding factors in this case, including a possible connection to preceding COVID-19 infection and ocular involvement, highlight its relevance for discussion. The male patient in his 70s initially presented to the emergency department with a headache for 2 weeks and vision loss in the right eye for 2 days; he reported no history of rhinosinusitis but did have rhinorrhea (a runny nose) 3 weeks prior and was diagnosed with COVID-19. Although he recovered from COVID-19, the patient developed a worsening right-sided headache 1 week later and right vision loss 2 days prior to presentation. The patient's right eye visual acuity at presentation was limited to hand-motion detection, with severe pain on ocular motion. CT scans revealed opacification with diffuse inflammation in all sinuses on the right side of his face, as well as erosion of the medial orbital apex bone. Emergency surgery and antibiotics were initiated. Bacterial cultures showed that this particular infection involved Streptococcus constellatus, which is associated with orbital invasion.

Histopathology images showsing (A) lymphocytes and plasma cells,
(B) IgG staining, and (C) mostly positive IgG4 staining

Histopathologic analysis of sinus samples showed dense infiltrate of IgG-containing plasma cells, with most being IgG4 positive; this finding was confirmed with elevated serum IgG4. IgG4-related rhinosinusitis was diagnosed and the patient was additionally prescribed prednisone and amoxicillin-clavulanate. At 3-week follow-up, the patient's vision had returned to baseline and his headaches had completely resolved. "Although rare, rheumatological workup for IgG4-RD in patients with severe rhinosinusitis and acute vision loss is critical because treatment of IgG4-RD differs from that of bacterial rhinosinusitis," the authors emphasize, "Hence, corticosteroids and antibiotics may be indicated in patients with severe rhinosinusitis until either IgG4-related or bacterial rhinosinusitis can be ruled out." They further state, "Importantly, this patient’s prior SARS-CoV-2 infection suggests a possible relationship between COVID-19 and IgG4-RD. Immunoglobulin G4-RD is mediated by cytotoxic CD4-positive T-cells, an atypical subset of helper T-cells with cytotoxic ability. Increased representation of cytotoxic CD4-positive T-cells was recently discovered in SARS-CoV-2 reactive T-cells, with higher levels associated with hospitalization. This finding signals a possible link between COVID-19 and IgG4-RD," although additional cases would be needed to differentiate between coincidence and connection between the two diseases.

My rating of this study: ⭐⭐⭐

Harb AA, Chen Y, Ben-Ami JR, et al. "Acute Vision Loss From IgG4-Related and Bacterial Rhinosinusitis After COVID-19." JAMA Otolaryngology Head Neck Surgery.  26 August 2021. https://doi.org/10.1001/jamaoto.2021.2121