Ocular infectious mononucleosis manifested as Parinaud's oculoglandular syndrome

Bilateral benign reactive lymphoid hyperplasia of the conjunctiva: a case treated with oral doxycycline and review of the literature

Background

To report a case of bilateral benign reactive lymphoid hyperplasia (BRLH) of the conjunctiva treated with oral doxycycline and perform review of the literature evaluating the presentation, treatment and risk of transformation to lymphoma.

Case presentation

A case report is described and review of the literature from January 1975 to January 2019 was performed. A 30-year-old man presented with bilateral enlarging fleshy pink medial canthal conjunctival lesions. Incisional biopsy revealed BRLH. Oral doxycycline was initiated (100 mg two times a day) for a total of 2 months. Both lesions decreased in size significantly at the patient’s two-month follow up visit. The residual lesion in the right eye was excised along with an adjacent pterygium and the patient has been free of recurrence for the past 1.5 years. The lesion in the left eye has remained stable in size after cessation of the oral doxycycline. A total of 235 cases of conjunctival BRLH were identified in our literature search. The mean age at diagnosis was 35.2 years (range, 5 to 91 years). BRLH lesions were unilateral in 75% of patients and bilateral in 25% of them. Seven patients (2.9%) had a concurrent Epstein-Barr virus (EBV) infection at the time of lesion appearance. The most common treatments were surgical excision (155/235 or 65.9%) and corticosteroids (30/235 or 12.7%), while 14% (33/235) of the patients were observed and 4.6% (11/235) received external beam radiotherapy alone. Recurrence occurred in ten patients (10/235 or 4.2%), of whom five had undergone surgical excision alone, two excision followed by external beam radiotherapy, one excision and oral corticosteroids, one radiotherapy alone and one had been treated with topical corticosteroids. Overall, only 2 of the 235 reported cases (0.8%) developed malignancy, one localized to the conjunctiva and one systemic.

Conclusions

Benign reactive lymphoid hyperplasia is one of the lymphoproliferative disorders of the conjunctiva and ocular adnexa. Extensive literature review shows that most cases are treated with surgery, steroids or observation. Oral doxycycline may be considered an alternative non-invasive treatment of BRLH conjunctival lesions. BRLH lesions warrant careful follow up as they can rarely transform into conjunctival or systemic lymphoma.

Isolated conjunctival granuloma as a first manifestation of Parinaud's oculoglandular syndrome: A case report

Purpose

Parinaud's oculo-glandular syndrome (POGS) is the most frequent manifestation of ocular bartonellosis, and usually presents with local lymphadenopathies and systemic symptoms. We present a case of isolated conjunctival granuloma as the sole manifestation of ocular bartonellosis.

Observations

A 67-year-old female presented to the authors’ eye clinic with complaints of a 2-week history of unilateral red eye and chemosis. Slit lamp examination revealed an isolated bulbar conjunctival granuloma. The remainder of the eye examination was unremarkable. Topical treatment with gatifloxacin and prednisolone acetate was started. Etiological work-up was performed. General laboratory tests revealed only a mild leukocytosis, and interferon gamma-release assay and chest computed tomography were normal. Serological testing for Bartonella henselae was positive at titers of 1:1024. Three weeks after initial symptoms, lymphadenopathies, malaise, and fever appeared. Systemic azithromycin was added, which resulted in complete regression of the disease.

Conclusion and importance

Conjunctival granulomas present a wide range of differential diagnoses to the practitioner. Ocular bartonellosis is a relevant cause of conjunctival granuloma. POGS should be suspected in cases of conjunctival granulomata non-responsive to local therapy. It is important to consider that other agents to treat POGS have been described and are available, and that appropriate serological tests should be performed.

Conjunctival tumor caused by Epstein-Barr virus-related infectious mononucleosis: Case report and review of literature

The conjunctival tumor associated with Epstein-Barr virus related infectious mononucleosis is a rare ocular manifestation. Only a few cases have been reported in the literature. We reported this rare condition that presented in a 5-year-old boy.

Parinaud'S oculoglandular syndrome associated with paracoccidioidomycosis

The authors report one case of Parinaud's oculoglandular syndrome associated with Paracoccidioides brasiliensis infection. No other medical report of this condition was found in the medical literature available at Index Medicus and Medline. The eye involvement has been rather uncommon in paracoccidioidomycosis and this report emphasizes the possibility of this kind of presentation making it also necessary to include paracoccidioidomycosis among the several known causes of Parinaud's oculoglandular syndrome.

Conjunctival lymphocytic infiltrates associated with Epstein-Barr virus

PURPOSE

To describe the clinicopathologic features of two patients with Epstein-Barr virus (EBV) associated conjunctival lymphocytic infiltrates.

DESIGN

Two case reports.

METHODS

The clinical histories and pathologic findings of two patients with salmon-colored conjunctival infiltrates are described.

MAIN OUTCOME MEASUREMENTS

Clinical observation and pathologic examination of conjunctival biopsy specimens with accompanying immunohistochemical staining, flow cytometric immunophenotyping, and polymerase chain reaction analysis when appropriate.

RESULTS

One patient had ipsilateral preauricular lymphadenopathy, elevated serum EBV titers, and a unilateral reactive lymphocytic infiltrate resulting in a conjunctival mass. The other patient had bilateral conjunctival lymphocytic infiltrates causing conjunctival masses. There was an expanded clonal population of B lymphocytes in the conjunctival mass in the second patient. Both patients had EBV antigen in their conjunctival lymphocytic infiltrates.

CONCLUSIONS

Conjunctival lymphocytic lesions associated with EBV represent a spectrum of reactive infiltrates to monoclonal populations.

Infectious mononucleosis presenting as a unilateral conjunctival tumour

A case of a unilateral conjunctival tumour as the initial manifestation in the course of acute infectious mononucleosis is reported. The tumour was observed two weeks before occurrence of fever, general malaise, and sore throat.

Conjunctival lymphocytic nodule associated with the Epstein-Barr virus

Infection with Epstein-Barr virus has been reported to have numerous systemic and ocular manifestations. In this study, a 38-year-old man with acute infectious mononucleosis was examined for a painless left red eye of three days' duration. The patient had a two-week history of fatigue, low-grade fever, sore throat, and lymphadenopathy. Serologic evaluation was indicative of an acute primary infection with Epstein-Barr virus. A large, salmon-colored, supranasal bulbar conjunctival mass was observed in the left eye. No associated conjunctivitis was present. Biopsy of the conjunctival lesion disclosed a dense leukocytic infiltrate, which consisted primarily of mature lymphocytes and plasma cells. Immunocytochemical evaluation of the tissue with monoclonal antisera disclosed Epstein-Barr latent membrane protein and nuclear protein 2 in a small fraction of the cells constituting the infiltrate. The conjunctival infiltrate resolved completely within one month, paralleling the regression of the patient's lymphadenopathy.

Ocular disease associated with Epstein-Barr virus infection

Epstein-Barr virus (EBV) is a ubiquitous DNA virus of the herpesvirus genus with a high prevalence rate for antibody (about 90%) in the adult population. It is the most common causative agent of infectious mononucleosis syndrome. During recent years an increasing number of ocular disease entities have been reported to be linked to EBV infection. These entities include oculoglandular syndrome, conjunctivitis, dry eye, keratitis, uveitis, choroiditis, retinitis, papillitis and ophthalmoplegia. While EBV-specific serologic tests can now document recent and past primary infection with EBV and also identify patients manifesting atypical immunologic reactions to EBV, the lack of an animal model, the absence of clear-cut response to therapy and the paucity of documentation by culture render the pathogenesis uncertain or the association questionable in many of these cases.

Detection of Epstein-Barr virus genomes in normal human lacrimal glands

Epstein-Barr virus (EBV) has been implicated in several ocular diseases; however, detection of the EBV genome in ocular tissues has not been documented. We report the detection of amplified EBV genomic sequences in 11 of 26 normal lacrimal gland DNA samples by using the polymerase chain reaction. Serum was available for 19 of the lacrimal gland donors. All 19 were EBV seropositive, although of the 19 lacrimal gland-seropositive patients, EBV sequences were detected in only 10 of the samples. Further, amplified EBV sequences were not detected in circulating lymphocyte DNA from normal seropositive volunteers, most likely because of the low frequency of circulating EBV-infected B cells. Amplification of EBV from cadaver lacrimal gland DNA was possible with minute quantities of DNA, whereas peripheral blood mononuclear cell DNA from normal volunteers did not amplify EBV sequences. Interestingly, the peripheral blood mononuclear cell polymerase chain reactions contained approximately 100 times more DNA than the lacrimal gland polymerase chain reactions. We conclude that the lacrimal gland may be a site for EBV persistence and that positive EBV serology is not an indicator of which individuals may have EBV harbored within their lacrimal glands.

Epstein-Barr viral stromal keratitis

We have identified seven patients with clinical and serological features suggestive of Epstein-Barr viral (EBV) stromal keratitis. Four had discrete, sharply demarcated, multifocal, pleomorphic or ring-shaped granular anterior stromal opacities with normal intervening stroma, seemingly distinct from adenoviral or herpes simplex stromal keratitis. Two had soft, blotchy, pleomorphic, multifocal infiltrates, predominantly involving the peripheral cornea at all depths, and with minimal neovascularization, resembling syphilitic stromal keratitis. One patient had features or both forms of keratitis. OUr experience suggests that EBV may be more commonly associated with stromal keratitis than recognized previously.