Bilateral Putaminal Haemorrhage and Blindness in Times of the Coronavirus Pandemic and Dysbiosis: Case Report and Literature ReviewAuthor(s): Humberto Foyaca Sibat*
Background: Bilateral putaminal haemorrhage (BPH) is a rare medical event caused by methanol intoxication, metastasis, bleeding disorders, and amyloid angiopathies. However, many other conditions can cause BPH and are discussed in this manuscript. We reviewed the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched for publications on BPH, but we did not find any publications reporting reversible bilateral blindness and bilateral ring putaminal haemorrhage.
Case report: A 34-year-old male patient is admitted to the neurology ward on a referral from a regional hospital. The patient complained of sudden-onset bilateral blindness lasting one day, with no other associated symptoms. MRI confirmed symmetrical bilateral putaminal haemorrhage.
Conclusion: To the best of our knowledge, this patient is the first one presenting bilateral putaminal haemorrhage and spontaneous and partial reversible prequiasmatic blindness reported in the medical literature. After a wide searching of available medical literature and detailed discussion, we concluded that our reported case is an atypical presentation of BPH, and blindness of unknown cause probably related with COVID-19, until proven otherwise. Our review of the medical literature concluded that MRI is the best investigation to assess basal ganglia pathologies due to its superior contrast resolution. Nonetheless, CT has a relevant role in detecting calcification; SW-MRI has poor accuracy, but when only one study is possible, SW-MRI is the best choice. We also concluded that in times of COVID-19 pandemic, all neuro-ophthalmological presentation (even with PCR negative) must be excluded from the extended list of clinical manifestations of SARS-CoV-2 infection-related and keeping in mind that most patients do not have respiratory symptoms. Based on revised articles, we have hypothesised that in times of coronavirus pandemic, peoples under severe and prolonged stress are more prompt to develop abnormal microbiome composition and dysfunctional immune system facilitating the acquisition of SARS-CoV-2 infection and an associated vascular damagecausing cerebrovascular diseases which aggravate neuroinflammation. Same mechanism explains the presence of optic neuritis. Further research is warranted to confirm a potential association between ICH/blindness/SARS-CoV-2 infection and the role played by microbiomes.
Abbreviations: DD: Differential Diagnosis, BL: Bilateral, BG: Basal Ganglia, WM: White Matter, WD: Wilson Disease, GP: Globus Pallidus, HD: Huntington Disease, PKAN: Pantothenate Kinase-associated Neurodegeneration, GM: Grey Matter, UL: Unilateral, CSF: Cerebrospinal Fluid, anti-CV2/CRMP5: Collapsing Response Mediator Protein 5, SWI-MR: Susceptibility-Weighted Magnetic Resonance Imaging, HIV: Human Immunodeficiency Virus, CT: Computed Tomography, DWI: Diffusion-Weighted Imaging, FLAIR: Fluid-Attenuated Inversion Recovery, dAVF: Dural Arteriovenous Fistula, PCNSL: Primary Central Nervous System Lymphoma, NF-1: Neurofibromatosis Type 1, ODS: Osmotic Demyelination Syndrome, CPM: Central Pontine Myelinolysis, EPM: Extra Pontine Myelinolysis, MRI: Magnetic Resonance Imaging, CJD: Creutzfeldt–Jakob Disease, ADEM: Acute Disseminated/ Demyelinating Encephalomyelitis, AHEM: Acute Haemorrhagic Encephalomyelitis, MOG: Myelin Oligodendrocyte Glycoprotein, rCBV: Relative Cerebral Blood Volume, AIDS: Acquired Immunodeficiency Syndrome, PRES: Posterior Reversible Encephalopathy Syndrome, PCR: Polymerase Chain Reaction, ULH: Unilateral Haemorrhage, TP the putamen, SW-MRI: Susceptibility-Weighted Magnetic Resonance Imaging, RNA: Ribonucleic Acid, DNA: Deoxyribonucleic Acid