Ocular manifestation and systemic abnormalities suggested malignant hypertension or Vogt-Koyanagi-Harada (VKH) disease. She was referred to the Department of Internal Medicine and the Obstetrical Department in our hospital.
Her height and body weight was 152 cm and 70 kg, respectively. Her body mass index was 30.3. The patient neurological status was normal. Her urine protein was 4+. Laboratory examination showed elevated liver enzymes and a low platelet count; the hemoglobin concentration was 15.0 g/dL (11.6–14.0 g/dL), hematocrit was 45.0% (34.1–41.7%), and the red blood cell count was 5.11 × 106/μL (3.66–5.8 × 106/μL), and the mean corpuscular volume was 88.1 fL (81.8–97.2 fL). The white blood cell count was 10,900/μL (normal range 2,800–8,800/μL), the blood platelet count was 88 × 103/dL (147–341 × 103/dL), blood urea nitrogen was 18 mg/dL (8–22 mg/dL), serum creatinine was 1.08 mg/dL (0.40–0.70 mg/dL), estimated glomerular filtration rate was 45 mL·min−1·L−1 (60 mL·min−1·L−1), aspartate transaminase was 45 U/L (13–33 U/L), alanine aminotransferase was 51 U/L (6–27 U/L), elevated lactase dehydrogenase was 648 U/L (119–229 U/L), alkaline phosphatase was 490 U/L (115–359 U/L), elevated C-reactive protein was 1.91 mg/dL (0.00–0.30 mg/dL), total protein in the blood was 5.4 g/dL (6.7–8.3 g/dL), serum albumin was 2.2 g/dL (3.9–4.9 g/dL), delayed prothrombin time was 148.7% (70.0–125.0%), and activated partial thromboplastin time was 26.3 seconds (23.0–38.0 seconds).
Central Serous Chorioretinopathy (CSC) in eclamptic patients or VKH disease should be considered as a differential diagnosis. Pregnancy is considered as a predisposing factor of CSC.27 However, the ground glass appearance of the choroid in the OCT images of our patient was different from that in the case of CSC. The lumen of a choroidal vessel is usually dilated and is clearly delineated in CSC.28 The choroidal and retinal characteristics in the OCT images of our patient seemed quite similar to those in VKH disease.29 VKH disease was ruled out because we could not find any sign of inflammation and the patient did not complain of symptoms related to VKH disease, such as a headache or tinnitus. Considering these facts, choroidal characteristics might be one of the adjunctive findings for making a diagnosis of HELLP syndrome.
However, we should consider the possibilities of the choroidal appearance on OCT in hypertensive chorioretinopathy or HELLP syndrome similar to VKH. In fact, it is not well known about the changes in the choroidal vessels under the severe hypertension. Kishi et al30 reported the pathology of hypertensive choroidopathy in monkeys with experimental malignant hypertension. They showed extensive occlusion of choroidal vasculature in the acute stage and recanalization in the chronic stage. The ground glass appearance of the choroid on OCT at an acute phase may indicate the occlusive changes, and the visualization of luminal structure of the choriocapillaris and Sattler layer after 6 days and Haller layer after 4 months may represent the recanalization of the choroidal vessels at chronic phase. However, as this is the first report on the choroidal morphology in HELLP syndrome, to our knowledge, the findings need to be confirmed with the accumulation of case reports in the future.
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