Herpetic Origin Research Articles

Bacterial keratitis – Challenges with changing microbial resistance

AbstractAbout 90% of corneal infections are bacterial in origin. The most common pathogens are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae and Pseudomonas aeruginosa. The two main causes of bacterial keratitis are contact lens usage and corneal injury.Patients typically complain of pain, sensitivity to light, blurred vision, tearing and yellowish purulent discharge. Clinical signs of bacterial keratitis include epithelial defect, ulceration in addition, stromal oedema and infiltrates with indistinct margins are present. Purulent material may appear in the anterior chamber.Most cases can be successfully treated with empiric therapy. If the pathogen is not known, moxifloxacin or cefazolin with tobramycin or gentamycin recommended as primary treatment. For severe keratitis eye drops should be applied both day and night for the first 48 hours. If the causative agent and its susceptibility are available from the microbiological sample and/or from smear, the topical treatment should be adjusted accordingly. If no improvement in the clinical picture seen after 48 hours with topical treatment, repeat sampling for microbiological culture recommended. In case of further progression, keratectomy with histological evaluation of the specimen is necessary. Corticosteroids may be considered after 48 hours when the infective organism is identified, and the keratitis is responding to therapy.In addition to antimicrobial treatment pupillary dilation advised to immobilize the iris and ciliary body. Cycloplegia may also decrease pain as well as synechia formation. In therapy resistant cases crosslinking may be an additional option if herpetic origin can be excluded.If the clinical picture does not improve, it is important to reassess the differential diagnosis of the keratitis caused by herpetic, fungal and Acanthamoeba infection.In cases of non‐healing and rapidly progressive corneal inflammation or ulceration, therapeutic corneal transplantation is recommended. However, surgery has a better prognosis in the non‐inflammatory period when the eye is quiet.

Corneal fine‐needle diathermy with intrastromal and subconjunctival injection of bevacizumab in a child with corneal neovascularization of herpetic origin

AbstractPurpose: Corneal neovascularization (CNV) in the paediatric population has a variety of etiologies including bacterial ulcers, herpes keratitis, exposure keratopathy, blepharokeratoconjunctivitis and corneal anaesthesia. Monotherapy with antiangiogenic agents or corneal fine‐needle diathermy (FND) alone do not completely resolve CNV; however, the combined treatment of these two seems to offer better results.Methods: We present the results of FND with adjuvant injection of intrastromal and subconjunctival Bevacizumab in a child with CNV of herpetic origin.Results: A 3‐year‐old patient who has been treated in our hospital for corneal involvement in the left eye (LE) due to herpetic keratitis of weeks of evolution comes to our consultation. Examination under general anaesthesia reveals in LE an inferior paracentral corneal leukoma with partial involvement of the visual axis and CNV that enters through the limbus from 5 to 8 h and begins to involve corneal stroma; no epithelial lesions, no corneal oedema or inflammatory activity in the anterior segment. After not improvement, it was decided to perform FND of lower CNV in conjunction with an intrastromal injection and another subconjunctival injection of Bevacizumab. Subsequently, it remains stable with topical and oral antiherpetic treatment, and topical corticosteroid therapy. At 3 months, the CNV reactivated, for which FND + intrastromal and subconjunctival bevacizumab was performed again. Finally, at 2 months, the patient is asymptomatic with VA LE of 1.0, with 2 corneal leukomas without CNV or epithelial lesions, and continues to be treated with oral acyclovir at prophylactic doses.Conclusions: FND of CNV together with adjuvant treatment with intrastromal and subconjunctival Bevacizumab is a good choice in children to treat those active corneal neovascularizations that do not respond to corticosteroid.

Anterior segment optical coherence tomographic characterisation of keratic precipitates

Background/objectivesAnterior segment optical coherence tomography (AS-OCT) can be used to visualise keratic precipitates (KPs) on the corneal endothelium. However, there has been no correlation between characteristic clinical appearances of KPs and AS-OCT morphology. We wished to assess the potential diagnostic role of AS-OCT in patients presenting with inflammatory eye disease and KPs. Subjects/methodsSix patients with inflammatory KPs were compared to one patient with infective interface keratitis following Descemet Membrane Endothelial Keratoplasty (DMEK) and one patient with endothelial pigment. AS-OCT was performed in each case and morphological features of the KPs were compared. Reflectivity of KPs was also compared numerically by measuring their relative lightness. ResultsAS-OCT images in acute and active inflammation generally demonstrated hyperreflective KP variants in comparison to conditions with moderate or longstanding inflammation. In the patient with infective interface keratitis, KPs were evident on the endothelial surface but no changes could be identified at the graft-host interface. There were no significant differences between infective and inflammatory KPs to help distinguish between the two. Endothelial pigment deposits were clearly differentiated from keratic precipitates with smaller, poorly defined deposits on the endothelium surface which were isoreflective to the cornea. ConclusionHyperreflective KPs could be suggestive of newly deposited KPs and active inflammation; they may also be increased in KPs of herpetic origin. AS-OCT should not be used to differentiate infective infiltrate from inflammatory KPs if a patient were to present with post-operative inflammation and interface infection should still be suspected even if only endothelial deposits are identified on AS-OCT. AS-OCT may be used as a diagnostic and monitoring tool to assess response to treatment in cases where anterior segment inflammation of uncertain aetiology is present.

Controversies between how to handle uveitis and glaucoma. The point of view of the uveitis specialist

SummaryUveitic glaucoma is often associated with high pressures and may damage the optic nerve faster than other forms of glaucoma. Therefore, early diagnosis and adequate treatment are essential. The key to successful treatment is an understanding of the pathogenetic mechanisms (secondary open‐angle, secondary angle closure, forward rotation of the ciliary body, etc.) Moreover, one should realize that combined mechanisms are more common in uveitic glaucoma than in other forms of glaucoma.Steroid‐induced pressure rise is common in uveitis patients and should be dealt with in a proper way: do not cut on steroids, but treat the glaucoma agressively. In those patients who have chronic uveitis and are steroid responders, surgery is a better option than medical treatment. Tubes are preferred over trabeculectomy with mitomycin in eyes with chronic inflammation.Contrary to some recommendations, prostaglandins should not be avoided in uveitis patients for fear of cystoid mcular oedema. They should be avoided however in uveitis of herpetic origin.

Bilateral herpetic keratouveitis in an immunocompetent patient

Case reportWe report the case of an immunocompetent male who presented with a limbal-adjacent scleritis and interstitial keratitis in the left eye. A few days later a new dendritiform ulcer in his right eye and bilateral progressive worsening with granulomatous uveitis in both eyes were observed. A thorough review of systems revealed positive serum IgM titles for herpes simplex virus. DiscussionIn the context of a bilateral keratouveitis refractory to conventional treatment it is mandatory to rule out the herpetic origin based on the different forms of clinical presentation of this virus.

Queratouveítis herpética bilateral en paciente inmunocompetente

Case reportWe report the case of an immunocompetent male who presented with a limbal-adjacent scleritis and interstitial keratitis in the left eye. A few days later a new dendritiform ulcer in his right eye and bilateral progressive worsening with granulomatous uveitis in both eyes were observed. A thorough review of systems revealed positive serum IgM titles for herpes simplex virus. DiscussionIn the context of a bilateral keratouveitis refractory to conventional treatment it is mandatory to rule out the herpetic origin based on the different forms of clinical presentation of this virus.

Herpetic ulcer of the eyelids in an immunocompromised patient

A 24-year-old black female (HIV-positive) was referred to our clinic with a 4-week history of an ulcerative lesion of the right upper and lower eyelids. She was on treatment for pulmonary tuberculosis and had been admitted to a secondary level hospital. She had no other ocular symptoms or signs. A tissue biopsy of the lesion revealed multinucleate squamous cells with ground glass viral nuclear inclusion bodies, indicative of herpes simplex virus (HSV) infection. The ulcer healed with oral and topical acyclovir therapy, confirming a herpetic origin. There is only one other reported case of this type of ulcerative eyelid lesion caused by HSV; the patient in this case was also immunocompromised.

Lymphangite récurrente du membre supérieur d’origine herpétique

Upper limb lymphangitis often complicates varied wounds on the hand or forearm and improvement is obtained in a few days with adapted antibiotic therapy. A 28-year-old woman presented since few years episodes of lymphangitis of the arm associated with vesicles on an erythematous base, on the palmar face of the first phalanx of the index finger, spontaneous relief within 10 days, without antibiotic therapy. Herpetic origin was confirmed on viral culture. No primary infection neither recurrence was noted. Because of the recurrences, a prophylactic treatment with valaciclovir was instituted. There was no reported recurrence at two years follow-up. Upper limb lymphangitis rarely complicates herpetic whitlow in immunocompetent patient. Clinicians should be aware of viral lymphangitis, which is often overlooked and associated with diagnostic errors and treatment delay.

HSV-1 antigens and DNA in the corneal explant buttons of patients with non-herpetic or clinically atypical herpetic stromal keratitis.

Little is known about the role of HSV-1 in keratitis not primarily attributed to herpetic origin. This study therefore aimed to prospectively evaluate the corneal explant buttons of patients with non-herpetic or clinically atypical herpetic stromal keratitis (experimental group: non-HSK) for the presence of HSV-1 antigens and DNA, and to compare the findings with those from individuals with typical herpetic stromal keratitis (positive control group: HSK) or non-inflammatory degenerative keratopathy (negative control group). Corneal buttons derived from 51 patients with HSK, from 72 with non-HSK and from 30 with degenerative keratopathy were prospectively collected and subjected to immunohistochemical analysis for HSV-1 antigens and to HSV-1 DNA amplification. In corneal buttons derived from patients with non-HSK, viral antigens were detected immunohistochemically in 8/72 cases and DNA amplified in 16/72. Corresponding values for the HSK group were 16/51 and 11/51. Taking viral antigen and DNA findings together, HSV-1 was detected in 18/72 (25%) patients with non-HSK and in 19/51 (37%) with HSK (p=0.2), but in only 2/30 (6%) individuals with non-inflammatory degenerative keratopathy. Since the detection frequencies for HSV-1 antigens and DNA were comparable in the HSK and non-HSK groups, Herpes may play an underestimated and as yet undefined role in non-herpetic and clinically atypical herpetic stromal keratitis, either as a primary trigger of the disease or as a secondary contributor to it. In this category of individuals, early anti-herpetic therapy should be considered if patients do not respond in the expected manner to treatment for non-herpetic stromal keratitis.

Neurogenic bladder in patients with acquired immunodeficiency syndrome.

We have performed a urodynamic study on 3 patients with acquired immunodeficiency syndrome (AIDS), presenting with a neurogenic bladder. The first patient had an ascending myelitis of probable herpetic origin, the second patient had a cerebral abscess caused by Toxoplasma gondii, and the third patient had an AIDS dementia complex. The urodynamic study showed an areflexic detrusor in the first 2 patients, and a hyperreflexic detrusor in the third patient.

Das Iridoplegie-Areflexie-Syndrom (Weill⁄Reys-Holmes-Adie), Symptomatik und Ätiologie als persistierende Herpes simplex-Virusinfektion

Looking for additional symptoms and signs of the iridoplegia-areflexia-syndrome referable to its unknown etiology we have found spotlike trigeminal numbness, edema, and/or redness suggestive of herpetic origin and more often common signs of herpes simplex virus-infection (HSVI). Indeed the whole picture of the syndrome as we see and describe it, can be explained by typical features of the HSVI. These include persisting HSVI of only the distal sensible or vegetative neurones and recurrence of infection with further destruction of ganglia-cells. These criteria are also decisive whether symptoms and signs may belong to the syndrome or not. To prove the hypothesis of HSVI etiology through other means is a necessity but seems to be difficult.

Comparison and evaluation of fluorescent antibody techniques in the detection of herpes simplex virus in oral infection

This article deals with the reliability and applicability of fluoroscopy in the diagnosis of herpetic lesions of the oral cavity. The reported results are based on a clinical experiment performed on fifty-two lesions suspected to be of herpetic origin. Three different methods were compared for detection of the possible presence of the virus—cytologic, virologic, and immunofluorescent. The greater reliability and speed of the last technique are demonstrated by our findings. Such features acquire special importance in the differential diagnosis of a number of diseases.

The Herpes-Encephalitis Problem

As already discussed in some detail in previous articles (Gay and Holden,18 1929; Gay,2 1932), we are confronted with a working hypothesis of considerable strength and value in attempting to explain the etiology of human epidemic (lethargic) encephalitis. The hypothesis that epidemic encephalitis is due to a modified or adapted neurotropic strain of the virus of herpes simplex has in our opinion grown in persuasiveness. We do not propose to repeat in detail the evidence for or against the herpetic origin of true epidemic encephalitis. It may suffice to present in a semitabular form the main lines of evidence which we have previously discussed more fully, underlining those particular arguments on which we propose to offer further evidence in this article, and referring interested readers to our previous papers for a fuller discussion.