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1 = 증례보고 = 대한안과학회지제 49 권제 5 호 2008 J Korean Ophthalmol Soc 49(5): , 2008 DOI : /jkos 수두에서발생한망막중심동맥폐쇄 김상혁 윤용준 김정열 충남대학교의과대학안과학교실 목적 : 수두환자에서발생한단안의망막중심동맥폐쇄를경험하였기에보고하고자한다. 증례요약 : 24 세여자가구심성발진과홍반을시작으로수포와가피가생겨개인병원에서수두로진단받고치료하던중 5 일째에갑작스런좌안시력저하가발생하여본원내원하였다. 내원당시좌안시력은광각유, 우안은 1.0 이었고안저검사상좌안의망막중심동맥폐쇄소견을보였다. 혈액응고이상을포함한전반적인혈액학적검사를시행하였다. 심장및경동맥은이상소견없었고, 일반적인혈액응고검사에서특이소견은보이지않았다. 항핵항체, 류마티스인자, 항인지질항체는음성이었다. 병변부조직생검및수두바이러스에대한중합효소연쇄반응검사에서양성으로나와수두와연관되어발생한망막중심동맥폐쇄로진단하였다. < 한안지 49(5): , 2008> 수두바이러스 (Varicella zoster) 는수두, 대상포진을일으킨다. 수두는대개아동기에일차감염으로발생하고, 대상포진은노인에서지각신경절에잠복해있던바이러스가재발하여발생한다. 1 수두바이러스감염는안과적으로눈꺼풀염, 결막염, 공막염, 각막염, 전부포도막염, 유리체염, 망막염등의합병증을일으키는것으로알려져있다. 수두후에심각한안과적합병증이발생하는경우는드물며 2 시력저하가발생하는경우또한드물다, 3 전신적수두감염이후망막중심동맥폐쇄가발생하는경우는더욱드물며, 아직까지국내에보고된바없다. 저자들은특별한과거력이없던젊은여자에서수두후에발생한단안망막중심동맥폐쇄를경험하여문헌고찰과함께보고하고자한다. 증례보고 24 세여자가내원일오후부터발생한좌안시력저하를주소로내원하였다. 환자는내원 5 일전구심성발진과홍반을시작으로수포와가피가형성되어개인병원에서수두진단받고경과관찰중이었다. 고혈압, 당뇨, 교원성질 < 접수일 : 2007 년 10 월 4 일, 심사통과일 : 2007 년 12 월 27 일 > 통신저자 : 김정열대전시중구대사동 640 충남대학교병원안과 Tel: , Fax: kimjy@cnu.ac.kr 환등을시사하는소견은없었으며, 안외상, 안수술력등의안과적과거력및가족력상의특이소견은없었다. 본원내원당시우안교정시력은 1.0, 좌안교정시력은광각유였다. 좌안대광반사는없었으며, 좌안에구심성동공운동장애가있었다. 골드만압평안압계로측정한안압은우안 11 mmhg, 좌안 12 mmhg 로정상범위였고, 세극등현미경을이용한전안부검사상특이소견은보이지않았다. 안저검사상좌안에서후극부망막혼탁과함께앵두반점을볼수있었고, 형광안저혈관조영에서동맥기와망막동맥정맥통과시간이지연되어나타났다 (Fig. 1, 2). 젊은사람에서발생한비전형적인망막중심동맥폐쇄를의심하여혈액검사를포함한정밀검사를시행하였다. 심장, 경동맥, 뇌혈관은이상소견없었고, 일반혈액검사또한특이소견은없었다. Prothrombin time 은 11.6 초 ( 정상 11.0~15.0 초 ), Activated partial thromboplastin time 은 29.3 초 ( 정상 22.4 초 ~40.4 초 ) 로정상범위내에있었으며 Protein C, Protein S 도정상범위였다. 매독혈청검사 (VDRL 검사 ), 항핵항체검사, 항인지질항체검사그리고 Rhematoid factor 는음성이었다. 피부의조직검사상수두로진단받았고, 혈액으로수두바이러스중합효소연쇄반응검사를시행한결과양성으로나왔다 (Fig. 3). 환자를수두에의한망막중심동맥폐쇄로진단하고안구마사지및전방천자를시행하였다. 내원 18 개월째인현재좌안의시력은광각유로변화없었으며, 안저검사에서망막동맥의협소화및시신경유두창백을볼수있었다 (Fig. 4). 853

2 김상혁외 : 수두에서발생한망막중심동맥폐쇄 Figure 1. Fundus photograph show whitening of the superficial retina and cherry-red spot in the left eye. Figure 2. Fluorescein angiograhs show delayed retinal arterial filling time and arteriovenous transit time in the left eye. 고 찰 수두바이러스 (varicella zoster virus) 는환자의연령대와면역상태에따라두가지전신질환을일으키 는데, 주로소아에서일차감염으로수두를일으키고, 세포매개성면역이저하되어있는노인층및면역결핍자에서는잠복상태에있던바이러스가재활성화되어대상포진을일으킨다

3 대한안과학회지제 49 권제 5 호 2008 년 Figure 3. The result of VAV-PCR in patient serum. Lane S1 demonstrating specific 200 bp amplification of the VZV band. (Lane M = 200bp DNA ladder; Lane PC = positive control; Lane NC = negative control; Lane S1 = blood sample from patient; Bp = base pair) 수두는발열, 식욕부진및기면등의전신적인증상과발병후 5 일간지속하는소양증을동반하는전신적인발진을특징으로하며자율적으로회복되는경미한질환이다. 진단은대개전형적인임상증상으로가능하고, 추가적검사에의한확진이필요한경우는드물다. 2 고위험군이나감염관리차원에서조속한확진이요구되는경우에는직접형광분석및중합효소연쇄반응검사를시행해볼수있다. 1,4 수두의합병증으로는피부및연조직의이차성세균감염, 중이염, 균혈증, 폐렴, 골수염, 화농성관절염, 심내막염, 괴사성근막염, 독소쇼크증후군, 간염, 혈소판감소증, 소뇌성조화운동불능, 뇌염등이있다. 1,2,4 수두바이러스에의해발생할수있는안과질환에는눈꺼풀염, 결막염, 각막염, 공막염, 전부포도막염, 녹내장, 백내장, 맥락망막염, 시신경염, 시신경위축, 안근마비, 급성망막괴사, 진행성망막외층괴사등이있다 일차감염에의한수두후에발생하는안과적합병증은대부분전안부에나타나고예후가좋은것으로알려져있다. 2 수두후안과적합병증에의해시력저하가발생하는경우는드물며몇차례보고된바가있다. 3 Capone and Meredith 15 는 2 세남아에서발생한시신경유두염과망막염에의해외사시와주시불안정이생긴경우를보고하였고, Purvin et al 16 은 14 세여아에서시신경염에의해시력이 0.02 로떨어진경우를보고하였다. 수두후에망막동맥이폐쇄되는경우는극히드물다. Hugkulstone and Watt 17 은 16 세여아에서전형적수두증세후발생한망막분지동맥폐쇄를보고하였다. Cho and Han 18 은 8 세여아에서수두후 5 일째발생한망막중심동맥폐쇄를보고하였고, Friedberg and Micale 19 은 5 세남아에서수두후발생한망막중심동맥폐쇄에대하여보고하였다. 이들은망막동맥폐쇄가급성망막괴사등에서볼수있는수두바이러스에의한동맥염에의해발생하는것으로보고하였다. 본증례의경우에서도비록광범위한혈관염을관찰할수없었지만, 이전보고에서와같이수두후발생한혈관염에의해발생한것으로추정된다. 결론적으로 24 세여자에서수두에의한발진 5 일후발생한단안의망막중심동맥폐쇄를경험하였고, 이는아직까지국내에보고된바없다. 전신검사상혈전증을일으킬만한다른소견은없었고, 피부생검및중합효소연쇄반응에서수두감염임을확진할수있었다. 이와같이젊은환자에서망막중심동맥폐쇄가발생하였을경우, 편두통, 심질환, 외상, 겸상적혈구증, 시신경드루젠, 유두앞혈관고리, 혈액응고이상등의잘알려진원인질환외에드물지만수두가원인이될수있음을알수있었다. Figure 4. Fundus photographs show disc pallor and arterial narrowing in the left eye at 18 months after the initial visit. 855

4 김상혁외 : 수두에서발생한망막중심동맥폐쇄 참고문헌 1) Vyse AJ, Gay NJ, Hesketh LM, et al. Seroprevalence of antibody to varicella zoster virus in England and Wales in children and young adults. Epidemiol Infect 2004;132: ) Macleod J. Davidson s priciples and practice of medicine, 19th ed. Vol. 1. Edinburgh: Churchill Livingstone, 1984:730. 3) Duke-Elder S. System of ophthalmology, 3rd ed. Vol. 15. London: Kimpton, 1976;167. 4) Hall S, Maupin T, Seward J, et al. Second varicella infections : Are they more common than previously thought? Pediatrics 2002;19: ) Ostler HB, Thygeson P. The ocular manifestations of herpes zoster, varicella, infectious mononucleosis, and cytomegalovirus disease. Surv Ophthalmol 1976;21: ) Liesegang TJ. The varicella-zoster virus: systemic and ocular features. J Am Acad Dermatol 1984;11: ) Appel I, Frydman M, Savir H, et al. Uveitis and ophthalmoplegia complicating chickenpox. J Pediatr Ophthalmol 1977;14: ) Chu W, Pavan-Langston D. Ocular surface manifestations of the major viruses. Int Ophthalmol Clin 1979;19: ) Edwards T. Ophthalmic complications of varicella. J Pediatr Ophthalmol 1965;2: ) Jordan DR, Noel LP, Clarke WN. Ocular involvement in varicella. Clin Pediatr 1984;23: ) Matoba A. Ocular viral infections. Pediatr Infect Dis 1984;3: ) Robb R. Cataracts acquired following varicella infection. Arch Ophthalmol 1972;87: ) Yoser SL, Forster DJ, Rao NA. Systemic viral infections and their retinal and choroidal manifestations. Surv Ophthalmol 1993;37: ) Garweg J, Bohnke M. Varicella zoster virus is strongly associated with atypical necrotizing herpetic retinopathies. Clin Infect Dis 1997;24: ) Capone A Jr, Meredith TA. Central visual loss caused by chicken-pox retinitis in a 2-year-old child. Am J Ophthalmol 1992;113: ) Purvin V, Hrisomalos N, Dunn D. Varicella optic neuritis. Neurology 1988;38: ) Hugkulstone CE, Watt LL. Branch retinal arteriolar occlusion with chicken-pox. Br J Ophthalmol 1988;72: ) Cho NC, Han HJ. Central retinal artery occlusion after varicella. Am J Ophthalmol 1992;114: ) Friedberg MA, Micale AJ. Monocular blindness from central retinal artery occlusion associated with chickenpox. Am J Ophthalmol 1994;117:

5 대한안과학회지제 49 권제 5 호 2008 년 =ABSTRACT= Central Retinal Artery Occlusion Associated with Chickenpox Sang Hyuk Kim, M.D., Young Jun Yun, M.D., Jung Yeul Kim, M.D. Department of Ophthalmology, College of Medicine, Chungnam National Univercity, Deajeon, Korea Purpose: To report a case of central retinal artery occlusion (CRAO) associated with chickenpox. Case summary: A 24-year-old female presenting with a history of centripetal eruption and erythema, followed by vesicle and eschar, was diagnosed with varicella and managed in a local medical clinic. Five days after the varicella eruption, she experienced decreased vision in her left eye. On initial exam visual acuity was light-sense positive in the left eye and 1.0 in the right eye; on fundus examination the patient was diagnosed with CRAO. We performed hematologic tests including thrombophilia studies, but there were no abnormal findings on routine hematologic tests, the carotid artery, or cardiovascular examinations. Antinuclear antibody, rheumatoid factor, and antiphospholipid antibody were negative. Skin biopsy and PCR results both corresponded with varicella, and the patient was diagnosed with CRAO associated with chickenpox. J Korean Ophthalmol Soc 49(5): , 2008 Key Words: Central retinal artery occlusion, Chickenpox Address reprint requests to Jung Yeul Kim, M.D. Department of Ophthalmology, Chungnam National University Hospital #640 Daesa-dong, Jung-gu, Daejeon , Korea Tel: , Fax: , kimjy@cnu.ac.kr 857

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