A 48-year-old male presented with complaints of severe headache of two-week duration. The headache was in the right parietal region accompanied by nausea and vomiting. There was neither any history of fever, photophobia, blurring of vision or diplopia, nor any significant past medical history. He was previously seen in another hospital; the brain Computed Tomography (CT) scan was reported to be normal.\nOn physical examination, the vital signs were within normal limits, and the patient was afebrile. Mental status examination did not reveal any abnormality. On clinical examination of the motor system, the tone and power in all the four limbs were normal with exaggerated (3+) reflexes. There was no neck stiffness, and Kernig’s sign was negative. Gait and coordination were normal. The sensory system and the cranial nerves were normal. Fundoscopy did not reveal any abnormality. No significant finding was revealed in other systemic examinations.\nRoutine full blood count and biochemistry did not show any abnormality. However, enzyme-linked immunosorbent assay (ELISA) of the patient’s serum was positive for anti- herpes simplex virus (HSV) IgM antibody. Lumbar puncture was not carried out since the patient refused it. The electroencephalogram (EEG) did not reveal any abnormality. The Magnetic Resonance Imaging (MRI) brain revealed bright T2/FLAIR cortical images at right parietal and temporal region ().\nA presumptive diagnosis of herpes simplex encephalitis (HSE) was made on the basis of serological and MRI findings; empirical treatment with intravenous acyclovir 750 mg eight hourly was initiated. He also received hydrocortisone 8 mg intravenous followed by oral prednisolone 40 mg daily. The headache was relieved, and the patient had no complaint while in the ward. A repeat brain MRI, which was done one week later, showed that the cortical enhancement has markedly reduced indicating response to treatment (). On discharge the patient was advised to repeat MRI and EEG after one week.\nThree weeks after the initial admission, the patient presented again with complaints of right retro-orbital pain of two days duration. The pain was accentuated with eye movements. The patient also noticed that he could not see clearly with the affected eye. Clinical examination revealed red colour desaturation and reduced visual acuity. Ophthalmoscopic examination showed a swollen right optic disc. Visual evoked potential (VEP) revealed small amplitude and delay in the right P100 latency (right: 122.40 ms, left: 113.10 ms). Right optic neuritis was diagnosed, which was treated with intravenous methylprednisolone 250 mg six hourly. The right eye pain was relieved, and the vision gradually improved. A diagnosis of post encephalitic right optic neuritis was made.
A 45-year-old woman suffering from intraocular hemorrhage associated with chronic myeloid leukemia complicated by subdural hematoma was referred to our institution. Chronic myeloid leukemia had been diagnosed 10 years earlier and the patient’s comorbidities were treated arterial hypertension, hepatitis B virus positivity, and orally treated type 2 diabetes mellitus diagnosed 3 years earlier. At presentation, she was in blast crisis for the second time and the disease was rapidly progressing. She was hospitalized in the Hematology-Oncology Department, University of Turin, with a very low platelet count (8,000/mm3) and red cell count (2,000 mm3), asthenia, fever, and occipital headache radiating to the anterior parts. A severe subdural hematoma was discovered, with ventricular dilatation and signs of high intracranial pressure. She was treated with repeated platelet transfusions and conservative medical therapy. The patient’s condition improved slowly, with progressive reabsorption of the hematoma and normalization of ventricular morphology on brain computed tomography scan.\nWe followed up this patient for a year by assessment of visual acuity, fundus examination, color retinography, and A-scan and B-scan ultrasonography. The patient complained of visual impairment in the left eye since the onset of her neurological symptoms, and was referred to our clinic. At presentation, her best corrected visual acuity on the right was 20/63 and on the left was 20/320. Retinal examination of the right eye revealed blurring of the optic margins surrounded by retinal and preretinal hemorrhages, preretinal fibrosis starting from the optic disc and extending along the vascular arcades, and perivascular retinal infiltrates (). Massive fibrosis with hard exudates and severe preretinal hemorrhage were observed in the left eye at the posterior pole (). The optic disc was surrounded by retinal and preretinal hemorrhages. Roth spots and many circular and preretinal hemorrhages were noted at the retinal periphery (). The other ocular structures were within normal limits. Ocular tension was good (right, 20 mmHg; left, 17 mmHg).\nA-scan and B-scan ultrasonography showed similar clinical features in both eyes, ie, an anechogenic vitreous cavity, a small increase in the thickness of the chorioretinal complex, and some minute retinal lines with higher reflectivity, likely representing hemorrhages. The patient was monitored for 12 months, with no changes in her clinical and functional characteristics.