Opportunistic infections increase morbidity and mortality in human immunodeficiency virus (HIV)-positive patients. Prophylaxis, including Hepatitis A vaccination (HAV), is recommended for all HIV-positive/Hepatitis A virus seronegative patients.1, 2 Here we describe the occurrence of unilateral autoimmune retrobulbar optic neuritis after HAV in a HIV-infected patient on anti-retroviral therapy (ART) with immune recovery.
Our patient is a 39-year-old HIV-infected Chinese male on ART (Lamivudine and Efavirenz). His CD4 count was 471 cells/mm3 (range 500–1600 cells) 3 weeks before receiving the first dose of attenuated HAV. He had not received any previous vaccinations after being diagnosed to be HIV positive. He found his vision in the left eye brighter than his right, 6 days after receiving HAV. This persisted until he developed sudden decreased central vision in his left eye, 12 days after vaccination. There was no associated pain on eye movements. Vision in the affected eye was counting fingers closely with a left relative afferent pupillary defect (RAPD), defective colour vision (0/15 Ishihara colour plates), and a central scotoma. There was no associated uveitis or optic disc swelling. Magnetic resonance imaging revealed left optic nerve enhancement with no compressive lesions (Figure 1). Infective (opportunistic) and autoimmune workup were negative. Lumbar puncture showed lymphocytic pleocytosis with otherwise no evidence of tuberculosis, syphilis, cryptococcus, or viral infection. He was treated with intravenous methylprednisolone for 3 days, with improvement of visual acuity (6/60) and colour vision (6/15 Ishihara plates) by day 3 of treatment. This was followed by a tapering course of oral prednisolone over 2 weeks with further improvement of visual acuity to 6/15 by 1 week and subsequently to 6/9, colour vision (15/15 Ishihara plates), and significant resolution of the central scotoma by 3 weeks (Figures 2 and 3). He has remained stable after a 14-month period of observation with a residual mild left RAPD, interval development of mild temporal disc pallor, and final visual acuity of 6/12. His CD4 counts remained stable at 444 cells/mm3 after 1 year.
Conflict of interest
The authors declare no conflict of interest.