Transient Monocular Visual Loss Research Articles

Comparison of vascular risk profile and clinical outcomes among patients with central (branch) retinal artery occlusion versus amaurosis fugax

BackgroundRetinal artery occlusions lead to sudden, painless vision loss, affecting millions globally. Despite their significance, treatment strategies remain unestablished, contrasting with acute ischemic stroke (AIS), where IVT has proven efficacy. Similar to AIS, retinal artery occlusions demand urgent evaluation and treatment, reflecting the principle "time is retina". Even for patients with transient monocular vision loss, also known as amaurosis fugax (AF), pertinent guidelines meanwhile recommend immediate emergency assessment in a specialized facility. However, data on the clinical benefit and comparability with persistent occlusions are missing. This study aimed to compare the results of a comprehensive stroke-workup among patients with persistent retinal artery occlusions (RAO), including both central retinal (CRAO) and branch retinal artery occlusion (BRAO) and those with AF.MethodsConducted at the University Hospital Giessen, Germany, this exploratory cross-sectional study enrolled patients with transient or permanent unilateral vision loss of non-arteritic origin. The primary outcome were differences between the two groups RAO and AF with regard to cardiovascular risk profiles and comorbidities, vascular and pharmacological interventions and clinical neurological and ophthalmological outcomes. Secondary outcome was a sub-group analysis of patients receiving IVT.ResultsOut of 166 patients assessed, 76 with RAO and 40 with AF met the inclusion criteria. Both groups exhibited comparable age, gender distribution, and cardiovascular risk profiles. Notably, RAO patients did not show significantly more severe vascular comorbidities than AF patients. However, AF patients received vascular interventions more frequently. Pharmacological intervention rates were similar across groups. RAO patients had slightly worse neurological outcomes, and IVT did not yield favorable ophthalmological outcomes within any observed patients.ConclusionThe study found similar vascular burden and risk factors in patients with RAO and AF, with implications for clinical workflows. IVT for RAO may only be effective in very early treatment windows. This emphasizes the need for public awareness and collaborative protocols between ophthalmologists and neurologists to improve outcomes.

Transient Monocular Visual Loss (Amaurosis Fugax): How Does Age Impact Diagnosis?

Transient monocular visual loss (TMVL), also known as transient monocular blindness or amaurosis fugax ("fleeting blindness"), is a temporary loss of vision often due to ischemia to the retina. While acute TMVL should be considered an emergency that further requires exhaustive investigation, there are some cases in which TMVL arises secondary to benign causes. Age has a major impact in the diagnosis of ischemia and although the differential diagnosis of TMVL can be broad, timely and appropriate history, examination, diagnostic testing, and treatment can be vision- or life-saving. We review the causes of TMVL and the impact of age on the differential diagnoses and management.

Abstract 17381: Relationship Between Amaurosis Fugax and Intraplaque Hemorrhage in Patient With Carotid Plaques

Introduction: The term amaurosis fugax is often used interchangeably to describe transient visual loss. However, it is employed widely in medicine to refer to any cause of transient monocular visual loss. Amaurosis fugax is associated with an imminent stroke and it could be linked to vascular thromboembolic events arising from the internal carotid arterial system. The aims of the study are to determine the plaque characteristics of patients who underwent carotid artery revascularization and the relationship of plaque characteristics with amaurosis fugax. Methods: Before elective carotid revascularization 44 patients (mean age 72±8 years; 25 males, 19 females) underwent 3-T MRI. After localization of the carotid bifurcation using phase contrast imaging, Time-of-Flight, 3D T1 weighting, transverse T1 and T2 weightings and proton density sequences were acquired. The different plaque components: lipid rich core, intraplaque hemorrhage, calcification and the characterization of the fibrous cap were assessed. Results: Carotid plaque samples had the following characteristics: Intraplaque hemorrhage (59%), surface defects (38.6%), stable fibrous cap (27.3%), lipid rich necrotic core (18%), and calcifications (11.4%). Amaurosis fugax history was identified in 7 patients (15.9%). Plaque samples from all 7 patients who had experienced amaurosis fugax revealed intraplaque hemorrhage. MRI revealed intraplaque hemorrhage in 19 (51%) patients without history of amaurosis fugax (p=0.016). The rest of the plaque characteristics did not show any statistically significant relationship with history of amaurosis fugax. Conclusions: This study demonstrated that intraplaque hemorrhage may be correlated to amaurosis fugax.

Abstract 101: Ophthalmic Artery Aneurysm Embolization Resulting in Resolution of Headaches and Visual Symptoms

Introduction Cerebral aneurysms are a rare cause of headaches and visual symptoms. Most common locations include anterior communicating artery, internal carotid arteries (ICAs), middle cerebral arteries, and tip of the basilar artery. While most unruptured aneurysms are asymptomatic, when symptoms do occur, they are most often headaches, cranial nerve palsies, or bilateral temporal hemianopsia due to compression of surrounding nerves or the optic chiasm. Rarely, thrombus formation within an aneurysm can lead to symptoms via distal embolization and infarction. The literature is limited regarding repeated aneurysmal microembolism formation or transient alterations in blood flow dynamics leading to episodic symptoms. Methods We report the case of a 55 year‐old woman with Ehlers‐Danlos syndrome and syringomyelia who presented to the hospital with one week of intermittent left eye visual disturbances, characterized by either complete transient monocular vision loss or blurriness lasting for 30 seconds at a time and occurring multiple times per day. These symptoms were also associated with pressure‐like headaches that originated around the left eye and radiated to the left side of her head. Results Neurological and ophthalmological examinations were notable for normal cranial nerve function, including intact visual acuity, visual fields, color vision and extraocular movements in each eye. On a dilated fundoscopic exam, there were no retinal or optic disc abnormalities. The rest of the neurological exam was normal. Head and neck CTA and subsequent digital subtraction angiography (DSA) showed multiple bilateral ICA aneurysms, as well as a 4 millimeter left ophthalmic artery aneurysm. Brain and orbits MRI with contrast showed no acute abnormalities, including no evidence of infarction or intracranial hemorrhage. She was started on clopidogrel due to concern for recurrent retinal transient ischemic attacks as well as escalating doses of nortriptyline for empiric treatment of possible ocular migraines. In follow‐up three months later, she continued to have the same visual and headaches symptoms. She underwent a successful elective flow diversion embolization of the ophthalmic artery aneurysm with subsequent resolution of her symptoms Conclusion Here we describe a case of a patient who presented with episodic monocular vision changes and headaches ipsilateral to an ophthalmic artery aneurysm, who experienced complete resolution of these symptoms following flow diversion embolization of the aneurysm. Although the precise pathophysiological relationship between the aneurysm and her visual symptoms is unclear, potential mechanisms include aneurysmal microthrombus formation with retinal embolization and dissolution, hemodynamic retinal blood flow changes related to the aneurysm, or recurrent ocular migraines triggered by the ophthalmic artery aneurysm.

Yield of Investigations in Young Patients Presenting With Transient Monocular Vision Loss: A Prospective Study

It is unclear whether transient monocular vision loss (TMVL) warrants the same thorough systemic evaluation for potential embolic sources in young adults as it does in older adults. The objective of the present study was to evaluate the yield of investigations in patients under 45 years old presenting with TMVL. Prospective cohort study. Young patients with TMVL presenting to a university-affiliated neuro-ophthalmology clinic were included. All included patient were referred for neuroimaging (CT or MR angiography of entire carotid tree and MRI of the brain) and cardiac investigations (transesophageal echocardiogram and 2 weeks Holter monitoring). Twenty participants with TMVL were included in the study. The mean age was 33.1 ± 8.2 years and 16/20 were women. The most common finding on past medical history was migraines, in 5 out of 20 cases (25%), and 25% of patients had headaches during their visual loss. Out of 17 participants who completed neuroimaging, 1 had fibromuscular dysplasia - this patient also experienced headaches during their symptoms. Two out of 13 patients who completed echocardiography had patent foramen ovale. Overall, 3 out of 20 participants (15%, 95% CI 3-38%) had abnormal findings associated with their TMVL. Aspirin treatment was initiated in 2 out of 3 patients following investigations. In our cohort of young patients presenting with TMVL, 15% of patients had abnormal findings on further investigations. We recommend that young patients presenting with TMVL be referred for neuroimaging and cardiac workup so that appropriate treatments can be initiated to prevent future complications. Headaches during the vision loss may not always indicate a benign cause, and retinal migraine should be a diagnosis of exclusion.

Prevalence and risk factors of ischemic monocular vision loss and concurrent brain ischemia.

We performed a retrospective cohort study to identify predictors of concurrent asymptomatic brain ischemia in patients with ischemic monocular vision loss. An inpatient database research of admissions to the Helios University Hospital Wuppertal, Germany between 01/2016 and 12/2020 was conducted. Inclusion criteria were confirmed diagnosis of transient monocular vision loss (MVL), retinal artery occlusion (RAO), and magnetic resonance imaging (MRI) of the brain within 10 days of MVL. Silent brain ischemia (SBI) was defined as diffusion restrictions with corresponding reduced apparent diffusion coefficient in MRI and an absence of neurological deficits besides those complying with MVL in clinical examination. The prevalence and cardiovascular predictors of SBI were analyzed with logistic regression and an artificial neural network. One hundred fourteen out of 475 patients treated with monocular vision loss were included in this study. The mean age was 67.7 ± 13.6 years. 48.2% were male and 47.4% had RAO. MRI scan of the brain was performed after 3.9 ± 2.3 days and detected SBI in 17%. Age ⩾67 years, cardiac etiology of MVL, and cerebral ischemia in medical history were revealed as predictors of SBI in MRI. Patients older than 66 years, with a suspected cardiac embolism as the cause of RAO and previous cerebral ischemia, are more likely to present SBI in cerebral MRI. Therefore, MR imaging, particularly in these patients, can be useful.

Ocular rosacea associated with transient monocular vision loss: resolution with oral metronidazole.

Ocular rosacea associated with transient monocular vision loss: resolution with oral metronidazole.

Abstract Number ‐ 122: Minimally symptomatic left M1 occlusion from carotid web

Introduction Minimally symptomatic large vessel occlusion (LVO) is an area of prognostic and management uncertainty. Current guidelines recommend thrombectomy only for patients with NIHSS of 6 or greater when additional timeline and imaging criteria are met. However, patients with initial mild or rapidly improving symptoms with LVO can eventually deteriorate, raising the question of whether all patient with acute LVO should be offered thrombectomy. Methods We present a case of minimally symptomatic M1 occlusion due to ipsilateral carotid web managed without thrombectomy. Results A 42‐year‐old woman with Systemic Lupus Erythematosus (SLE) and hypertension presented to an outside hospital with sudden transient left monocular vision loss, aphasia, right‐side weakness, and dizziness. At the time of presentation (1h from LKW) exam revealed only mild aphasia (NIHSS 1) with normal blood pressure. CTA demonstrated left M1 occlusion with reconstitution of flow at the M2 bifurcation. She was given IV Alteplase and transferred to our center. On 7 h from LKW repeat imaging demonstrated persistence of the left M1 occlusion with an ipsilateral near‐occlusion suspicious for carotid web at the ICA origin, but exam was without deficit. She was monitored closely for neurological deterioration, but remained without significant symptoms. MRA taken the next day demonstrated complete recanalization of the left M1. She was taken to the angiography suite on an outpatient basis for stenting of the carotid web at the origin of the internal carotid artery. Initial diagnostic angiogram revealed near occlusion of the ICA at the origin with post‐stenotic dilation, which was treated with angioplasty and stenting with distal embolic protection. She has remained stable to 8‐month follow‐up with no recurrent stroke. Conclusions Minimally symptomatic LVO presents significant endovascular management uncertainty. While clinical trials support the use of mechanical thrombectomy for significantly symptomatic patients, there is no consensus to guide treatment decisions for patients with minimal symptoms. This uncertainty is driven at least in part by an inability to reliably distinguish between patients who are likely to progress and would benefit from intervention before their collateral circulation fails, and those who will recanalize or develop a compensated chronic occlusion. In this case, our patient received tPA and saw symptom improvement, but this did not remove her M1 occlusion. Angiographic investigation was limited as the patient was asymptomatic, however non‐invasive imaging revealed robust collateralization including reconstitution of MCA flow and left ICA injection failed to opacify the ipsilateral ACA despite patency in recent CT angiography, indicating a right to left flow dominance in circle of Willis collaterals. We opted for close monitoring with follow‐up imaging and outpatient correction of the carotid web, which resulted in a positive outcome. More work is needed to establish criteria to predict which patients with minimally symptomatic LVO are likely to progress.

Retinal migraine, a contentious clinical entity

" Retinal migraine (ophthalmic migraine, ocular migraine, anterior visual pathway migraine) is a rarely encountered medical condition, but with an interesting and complex clinical presentation. The goal of this article is to compile the literature on retinal migraine, detailing nomenclature, pathophysiology, differential diagnosis, and medical investigations including newer imaging modalities, like optical coherence tomography (OCT). We will approach topics of great concern such as risk factors, complications, treatment, and management of this condition. Retinal migraine is mainly a diagnosis of exclusion and it must be isolated from transient monocular vision loss (TMVL) developed from other causes, for instance, papilledema, giant cell arteritis, carotid artery disease (amaurosis fugax), intermittent angle closure glaucoma, and others. Its treatment is similar to migraine treatment; topiramate, amitriptyline, and nortriptyline are some of the pharmacological drugs successfully used."

Transient Bilateral Central Scotoma on Awakening: A Distinct Phenomenon.

Transient vision loss can be an alarming symptom owing to potentially serious etiologies such as thromboembolism or giant cell arteritis. Transient monocular vision loss (TVML) on awakening has been recently described as a benign phenomenon (Bouffard et al, 2017). Our objective was to describe the unique phenomenon of transient binocular vision loss (TBVL) on awakening. Retrospective observational case series of 5 patients who experienced TBVL on awakening seen in the neuro-ophthalmology clinic at the Mayo Clinic between 2016 and 2020. Patients who described generalized blurred vision and those with monocular transient vision loss were excluded. The median age was 81.4 years (range, 68-92 years), and all were male. Every patient described a stereotyped transient bilateral central scotoma on awakening with slightly irregular borders and mild asymmetry between the 2 eyes lasting between 15 and 90 minutes. Frequency ranged from 3 to 7 times per week, and there was a median of 319 episodes (range, 126-728 episodes) before evaluation in the neuro-ophthalmology clinic. All patients had normal optic nerves, and no plaques were noted in the retinal vessels. All 5 had macular drusen, which were predominantly extrafoveal and mild. Two patients underwent electrophysiology testing, which were both normal on full-field electroretinogram (ERG), but there was blunted central wave forms on multifocal ERG. Two patients underwent dark adaptation testing, which showed both prolong and diminished dark adaptation. Neuroimaging and thromboembolic workup were unrevealing. TBVL is a distinct phenomenon from TMVL on awakening, which has a different demographic and symptomology. The etiology is unclear but seems to be a focal macular process in conjunction with an autoregulatory failure resulting in a supply-demand mismatch during low-light conditions.

Endocarditis with disseminated thromboembolisms and hypercoagulable state

Ten months after radical cystectomy and adjuvant chemotherapy for an anaplastic giant cell bladder cancer (pT2N2M0), a 41-year-old woman presented with a 4-week history of intermittent claudication, lower right back pain, transient monocular vision loss, and fever.

Co-Occurrence of Two Rare Sleep-Related Neuro-Ophthalmologic Phenomena: Transient Monocular Vision Loss on Awakening and Sleep-Induced Apraxia of Eyelid Opening (Awakening Ptosis).

Co-Occurrence of Two Rare Sleep-Related Neuro-Ophthalmologic Phenomena: Transient Monocular Vision Loss on Awakening and Sleep-Induced Apraxia of Eyelid Opening (Awakening Ptosis).

Nationwide trends in emergency department utilisation for acute retinal ischaemia in the USA, 2011–2018

BackgroundGuidelines recommend urgent evaluation for transient monocular vision loss (TMVL) and retinal artery occlusion (RAO), but emergency department (ED) utilisation for these conditions is unknown.MethodsWe performed a retrospective longitudinal cross-sectional...

Multiple attacks of transient monocular visual loss in a previously healthy man: a possible complication after COVID-19 vaccination?

BackgroundThe present case aims to describe a previously healthy man who presented multiple attacks of transient monocular visual loss after Pfizer-BioNTech COVID-19 vaccination and to discuss the possible mechanisms related to occurrence of this condition.Case presentationWe report a case of multiple attacks of transient monocular visual loss in a previously healthy middle-aged man two weeks after Pfizer-BioNTech COVID-19 vaccination. TVL attacks were described as sudden and painless complete visual loss, lasting about one minute, followed by a full recovery. He presented several non-simultaneous attacks in both eyes, 16 in the right eye, and 2 in the left eye on the same day, fifteen days after receiving the second dose of the Pfizer-BioNTech COVID-19 vaccine. The brain’s magnetic resonance angiography, echocardiogram, and doppler ultrasound imaging of the carotid and vertebral arteries were non-revealing. The complete blood exam revealed a slightly elevated C-reactive protein test. We assessed fundus examination during the transient visual loss attack and revealed diffuse vascular narrowing for both arterial and venous branches, notably in the emergence of the optic disc in right eye. In addition, the circumpapillary optical coherence tomography angiography (OCTA) vessel density map was reduced. Oral verapamil hydrochloride 60 mg twice daily was initiated, and the attacks of transient visual loss improved after two days.ConclusionsTo date, and the best of our knowledge, this is the first case report of multiple transient monocular visual loss attacks due to retinal vasospasm in a previously healthy middle-aged man documented by fundus retinography and OCTA. We discuss in this article the possible association of retinal vasospasm and Pfizer-BioNTech COVID-19 vaccination, probably related to vaccine-induced inflammation.

Transient Monocular Visual Loss Induced By Celecoxib: A Rare Adverse Effect

Background: The cyclooxygenase (COX) enzymes are competitively inhibited by nonsteroidal anti-inflammatory medications (NSAIDs). COX enzymes come in two distinct isoforms, each of which is encoded by a separate gene and has its own expression pattern. The therapeutic anti-inflammatory impact of NSAIDs is obtained by inhibiting COX-2 activity, whereas the majority of the unwanted side effects are caused by inhibiting COX-1 activity. As a result, selective COX-2 inhibitors are thought to have fewer negative effects. Medical disciplines such as rheumatology and orthopedics routinely prescribe COX-2 inhibitors like Celecoxib for the management and control of acute and chronic pain. Celecoxib is a medicine that is thought to be safe. Celecoxib, like other NSAIDs, can have side effects, the most prevalent of which are to the gastrointestinal (GI), cardiac, and renal systems. Ocular problems, which are included in the prescribing label as a potential concern, are among the less usually reported adverse effects of Celecoxib. Blurred vision, conjunctivitis, cataracts, and eye pain are among the side effects. More uncommon ocular problems have been recorded, including acute temporary and even severe permanent vision impairment. To my knowledge, this is the first published study on Celecoxib-related monocular vision loss. Keywords: Cyclooxygenase (COX) enzymes, Ocular problems,

Eye Signs in Stroke.

A large part of the central nervous system is involved in the normal functioning of the vision, and hence vision can be affected in a stroke patient. Transient visual symptoms can likewise be a harbinger of stroke and prompt rapid evaluation for the prevention of recurrent stroke. A carotid artery disease can manifest as transient monocular visual loss (TMVL), central retinal artery occlusion (CRAO), anterior ischemic optic neuropathy or ocular ischemic syndrome (OIS). Stroke posterior to the optic chiasm can cause sectoranopias, quadrantanopias, or hemianopias, which can be either congruous or incongruous. Any stroke involving the dorsal stream (occipito-parietal lobe), or ventral stream (occipito-temporal lobe) can manifest with visuospatial perception deficits. Similarly, different ocular motility abnormalities can result from a stroke affecting the cerebrum, cerebellum, or brainstem. Among these deficits, vision and perception disorders are more difficult to overcome. Clinical, experimental, and neuroimaging studies have helped us to understand the anatomical basis, physiological dysfunction, and the underlying mechanisms of these neuro-ophthalmic signs.

Current Perspective on Retinal Migraine.

Retinal migraine was first formally described in 1882. Various terms such as “ocular migraine” and “ophthalmic migraine” have since been used interchangeably in the literature. The lack of a consistent consensus-based definition has led to controversy and potential confusion for clinicians and patients. Retinal migraine as defined by the International Classification of Headache Disorders (ICHD) has been found to be rare. The latest ICHD defined retinal migraine as ‘repeated attacks of monocular visual disturbance, including scintillation, scotoma or blindness, associated with migraine headache’, which are fully reversible. Retinal migraine should be considered a diagnosis of exclusion, which requires other causes of transient monocular visual loss to be excluded. The aim of this narrative review is to summarize the literature on retinal migraine, including: epidemiology and risk factors; proposed aetiology; clinical presentation; and management strategies. It is potentially a misnomer as its proposed aetiology is different from our current understanding of the mechanism of migraine

Stroke Risk before and after Central Retinal Artery Occlusion: A Population-based Analysis

To determine the risk of stroke, transient ischemic attack (TIA), and transient monocular vision loss (TMVL) before and after a central retinal artery occlusion (CRAO). Population-based, retrospective case series. Patients diagnosed with a CRAO in Olmsted County, Minnesota, from 1976 to2016. Patients living in Olmsted County with a diagnosis code of CRAO from 1976 to 2016 were reviewed. New CRAOs were confirmed, and stroke, TIA, and TMVL events in the 15 days before and after CRAO were recorded. Incidence of stroke, TIA, and TMVL events in the 15 days before and after CRAO. Eighty-nine patients with a CRAO were identified, providing an annual incidence of 2.58/100 000 (95% confidence interval [CI], 2.04-3.11). Median age at the time of CRAO was 76 years (range, 46-100 years); 56.2% were male, and 89.9% of the cohort was White. In the 15 days before and after CRAO, there were 2 ischemic strokes (2.2%), 1 hemorrhagic stroke (1.1%), 2 TIAs (2.2%), and 9 TMVL events (10.1%). Starting in 1999, 15 of 45 patients underwent magnetic resonance imaging within 2 months of CRAO. One patient (6.7%) had evidence of asymptomatic diffusion restriction, and 9 patients (60%) had a remote infarct. This population-based study demonstrated that the risk of symptomatic ischemic stroke is 2.2% in the 15 days before and after a CRAO, which is slightly lower than most studies from tertiary centers. These data should be considered as practice recommendations are developed regarding the urgency of neurovascular workup in patients with acute CRAO.

Optic disc vascular malformation with venous stasis and macular edema

Arteriovenous malformations are abnormal tangled blood vessels with multiple irregular connections between arteries and veins. These malformations can occur anywhere with a preponderance to the spinal cord and brain.AV-malformations are usually congenital and patients might also have an associated intracranial aneurysm. Ophthalmic manifestations of AVM depend upon the location, varying from being asymptomatic to visual phenomena, field defects, diplopia, nystagmus etc.AV malformations in the cortical or occipital lobe produce visual symptoms which are transient. They can be associated with scotomas and migraine type headache. Signs and symptoms of brainstem AVMs are nonspecific and may include diplopia, nystagmus, dizziness, ocular motor nerve palsy, gaze palsy, anisocoria, or pupillary light–near dissociation. Findings are usually unilateral. There can be transient monocular vision loss due to the “steal phenomenon” in rare cases.Diagnosis of an AVM are based on angiographic findings which demonstrate an engorged arterial system, rapid filling of the malformation and outflow of the venous system.

Acute retinal arterial ischaemia: silent brain infarcts prevalence and short-term recurrence.

The purpose was to evaluate, in a consecutive series of patients with isolated acute retinal ischaemia, the proportion of patients with acute silent brain infarcts (SBIs) on diffusion-weighted imaging (DWI) and to assess risk of recurrence within 3months. In all, 103 consecutive patients with isolated acute retinal ischaemia (central retinal artery occlusion, branch retinal artery occlusion or transient monocular vision loss) were included between January 2015 and December 2016. They all had cerebral magnetic resonance imaging including DWI as well as a standardized aetiological workup and 3months of follow-up. The presence of DWI-positive cerebral lesions was recorded. Main clinical and radiological characteristics between DWI-positive and DWI-negative patients were compared. Of the 103 patients (including 42 transient monocular vision loss), 20 (19.5%) had SBIs on DWI, which were ipsilateral to the acute retinal ischaemia in 30% and involved different and/or multiple vascular territories in 70% of cases. Ipsilateral carotid stenosis and occlusion were respectively identified in 17 and eight patients whereas cardioaortic embolism was found in 19 patients. Overall, patients with and without acute SBIs were comparable. The topography of SBIs was related to the aetiology of the acute retinal ischaemia. At 3 months of follow-up, one patient suffered from ischaemic stroke and five had recurrent retinal ischaemia. Irrespective of the baseline characteristics of the patients, SBIs are present in about 20% of patients with isolated acute retinal ischaemia and may be of interest in the aetiological workup. Overall risk of recurrence is low, favoured by rapid aetiological workup and appropriate treatment.