Late ophthalmologic manifestations of neonatal herpes simplex virus infection

A case of hypertrophic herpes simplex virus affecting the eyelid and cornea masquerading as IgG4-related disease

Purpose

To report a case of hypertrophic herpes simplex virus (HSV) of the eyelid and cornea masquerading as IgG4-related disease.

Observations

A 37-year old African American female with a past medical history of human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) and a recent history of treated genital herpes, presented with an ulcerative lesion of the left upper and lower eyelids, and severe ocular inflammation with symblepharon. Initially, eyelid biopsy revealed findings consistent with IgG4-related disease, and the patient was treated with high dose oral prednisone. After one week of therapy, there was no improvement in the patient's symptoms, and she subsequently developed a corneal epithelial defect which progressed to chronic ulceration. Repeat biopsy and corneal cultures revealed herpes simplex virus type 2. The patient was treated with high dose acyclovir, and the lid lesion improved. The conjunctival inflammation and corneal epithelial defect resolved but symblepharon restricting her eye movement remained. She also developed corneal vascularization and opacification causing severe vision loss.

Conclusions and importance

Chronic hypertrophic herpes simplex virus infection is a rare condition reported in patients with HIV. While there have been few reports of hypertrophic HSV affecting the eyelid, this is the first reported case of hypertrophic HSV affecting the eye, resulting in severe vision loss.

Visual function in preterm infants: visualizing the brain to improve prognosis

Considerable development of the visual system occurs in the third trimester of life, a time when very preterm-born infants are in a neonatal intensive care unit (NICU). Their very early birth during a period of rapid and marked neurodevelopment and their clinical course makes them a very high-risk population. A range of different events impacts brain development and the visual system, leading to significant long-term visual dysfunction. Improved neuroimaging techniques provide an important window on the early brain and visual system development of these vulnerable infants. Greater understanding of the etiology of visual impairment subsequent to preterm birth and the timing of critical processes will allow early recognition and the earlier implementations of interventions. In the longer term, this will help clinicians optimize NICU practice to reduce the incidence of visual dysfunction in these children.

Brain injury and the eye

Visual loss associated with brain damage is the single greatest cause of visual impairment in children in developed countries. Damage may occur in any of five separate visual systems: primary visual cortex, visual associative cortex area, optic radiations, optic nerves, and visual attention pathways. Improving our understanding of the pathophysiology of these causes for visual loss may lead to better rehabilitation and educational strategies for these children.

Visual function in the brain-damaged child

The essential role of the primary visual cortex in visual processing has been extensively studied over the last century or more. Injuries to the visual cortex in adult humans can produce blindness, referred to as "cortical blindness". In children some degree of visual recovery has been noted in comparable injuries and for that reason the term "cortical visual impairment" has been suggested as a more appropriate diagnosis in children. This term is, however, inaccurate as a significant number of children with visual loss and neurologic damage have injuries to the noncerebral pathways (for example--optic radiations in children with periventricular leukomalacia). In this study we compare visual outcomes and recovery in children with primary visual cortex lesions vs those with periventricular leukomalacia. We suggest that the poorer outcomes of children with periventricular leukomalacia could have been predicted based on studies of the mechanisms of visual recovery in infant animals following visual cortex ablation.

Twenty years' delay of fellow eye involvement in herpes simplex virus type 2-associated bilateral acute retinal necrosis syndrome

PURPOSE

To describe a case of acute retinal necrosis with concurrent encephalitis and determine the causative virus. The patient had a history of presumed acute retinal necrosis in the left eye at the age of 8 years and recurrent genital herpes.

METHODS

Diagnostic anterior chamber puncture of the eye and lumbar puncture for laboratory analysis.

RESULTS

Polymerase chain reaction identified herpes simplex virus type 2 in the eye, and local antibody production to herpes simplex virus was demonstrated in the aqueous of this eye and in the cerebrospinal fluid.

CONCLUSION

Herpes simplex virus type 2 may cause bilateral acute retinal necrosis with long delay of fellow eye involvement and concurrent encephalitis.

Neonatal herpes simplex infection: keys to early diagnosis

OBJECTIVE

To highlight the clinical features of neonatal herpes simplex (HSV) infection that might facilitate earlier diagnosis.

METHODOLOGY

Fifteen year retrospective review of proven neonatal HSV cases from a regional neonatal referral unit.

RESULTS

Fifteen cases reviewed: 10 with central nervous system (CNS) disease, three with skin, eyes or mouth (SEM) disease and two with disseminated disease (DIS). A median 4 day delay occurred between symptom onset and hospital admission. All cases presented after maternity hospital discharge, most commonly with feeding problems and lethargy. Six patients presented with skin lesions; parental genital herpes was reported in three (20%) cases. Seven infants died, four without acyclovir treatment and three of 11 treated cases. Three of five CNS disease survivors and all infants with SEM disease were normal at follow up.

CONCLUSIONS

Acyclovir improves outcome in neonatal HSV infection. To improve outcome further earlier recognition of the non-specific presenting features of the disease is required.

Acute retinal necrosis caused by reactivation of herpes simplex virus type 2

Acute retinal necrosis is a severe form of necrotizing retinitis. Acute retinal necrosis has been demonstrated to be caused by varicella-zoster virus and herpes simplex virus type 1. We treated three patients with acute retinal necrosis apparently caused by recrudescence of latent herpes simplex virus type 2. Primary viral infection was probably congenital, with documented perinatal herpes simplex virus type 2 infection in two patients. Bilateral chorioretinal scars were present in two patients, neither of whom had a history of ocular herpetic infection, suggesting that earlier subclinical chorioretinitis had occurred. In each case, periocular trauma preceded the development of retinitis by two to three weeks. These cases are evidently caused by trauma-induced reactivation of latent virus rather than the onset of a primary infection.

A thymidine kinase deficient HSV-2 strain causes acute keratitis and establishes trigeminal ganglionic latency, but poorly reactivates in vivo

The incidence of herpetic keratitis following intranasal or direct ocular infection with thymidine kinase-negative (TK-) strains of herpes simplex virus (HSV)-2 has not been well studied, and the role of the TK gene in the establishment of latency and virus reactivation is controversial. To determine whether a TK- strain of HSV-2 could establish trigeminal ganglionic latency and be reactivated in vivo to produce recurrent keratitis or nervous system infection, an animal model of acute and recurrent infection was utilized. Rabbits were infected by the intranasal or ocular routes, and latency was reactivated by immunosuppression. Virus shedding in nasal and ocular secretions was monitored, and the eyes were examined for the presence of corneal epithelial lesions during acute and reactivated infections. Central nervous system (CNS) and trigeminal ganglionic tissues were assayed by histologic, virologic, and in situ hybridization techniques. All rabbits intranasally infected shed virus in both ocular and nasal secretions, whereas only 30% of rabbits infected in the eyes shed virus in nasal secretions. Virus was recovered from cocultivation cultures, but not from cell-free homogenates, of trigeminal ganglionic and CNS tissues from animals inoculated by both routes. The incidence of keratitis was much greater after direct ocular inoculation, although both routes of inoculation produced CNS and ganglionic inflammatory lesions. Keratitis healed in 92% of the animals infected by the ocular route by 26 days post infection. Of rabbits initially infected in the eyes and then subjected to drug-induced reactivation, only 30% shed virus, which was limited to a 24 hour period; there was no reappearance of epithelial keratitis, no animal became blind, and none died. In contrast, latently infected control rabbits uniformly reactivated. These studies show that this TK-HSV-2 strain (i) replicates in the eye, (ii) is neuroinvasive but non-neurovirulent following intranasal and direct ocular infection; (iii) sheds in the eye more frequently and for longer periods after ocular than after intranasal inoculation; (iv) induces epithelial keratitis that usually heals spontaneously; (v) establishes latency in trigeminal ganglionic neurons, but no other ganglionic cells; and, (vi) reactivates in a small proportion of animals, but does not produce recurrent ocular lesions following drug-induced immunosuppression. Thus, the TK gene appears directly involved in HSV latency and reactivation in vivo.

Cortical visual impairment in children

Cortical visual impairment (CVI) in children is most commonly caused by peri- or post-natal hypoxia-ischemia, but may also occur following other insults, e.g., trauma, epilepsy, infections, drugs or poisons, and certain neurologic diseases. The disorder differs considerably in etiology, physical findings, and, perhaps, prognosis, from the cortical blindness seen in adults. The same event that causes CVI by damaging the geniculate and/or extrageniculate visual pathways may also damage other areas of the brain, or the retina, optic nerves, or chiasm. Thus, children with CVI often have other neurological problems. Diagnosis may require the participation of a multidisciplinary team and the use of special visual testing techniques. Due to the uncertainty concerning the prognosis in CVI, clinicians should remain optimistic about the child's potential for some vision recovery.

Systemic viral infections and their retinal and choroidal manifestations

Viruses are one of the most common causes of infections involving the posterior segment of the eye. Such infections can occur either on a congenital or an acquired basis, and may affect primarily the retina or the choroid. Congenital cytomegalovirus (CMV) and rubella infections may result in retinitis. CMV retinitis is also the most common cause of acquired viral retinitis, primarily because of the acquired immunodeficiency syndrome (AIDS). Other types of viral retinitis, such as those caused by herpes simplex or herpes zoster, can occur in immunocompromised or immunocompetent individuals. Retinitis or choroiditis caused by viruses such as measles, influenza, Epstein-Barr virus, and Rift Valley fever virus, typically occurs subsequent to an acute viral systemic illness. The systemic and ocular manifestations, as well as the histopathology, laboratory tests, differential diagnoses, and treatment regimens for each of the individual viruses are discussed in detail.

Congenital diffuse necrotizing herpetic retinitis

Neonatal Herpes simplex infections are usually contracted from the birth canal, and the systemic lesions develop several days to weeks after delivery. We present the clinicopathologic findings in a newborn with a prenatal diagnosis of hydrocephalus who died at 1 day of age. Severe liquefaction necrosis and foci of calcification were present in the brain, adrenal glands, and retina. Cowdry type A intranuclear inclusions were present in the adrenal glands and retina. There was no clinical evidence of genital herpes in either parent. This is the first documented case of in utero transmission of Herpes simplex infection, confirmed by the polymerase chain reaction, and causing fulminant necrotizing retinitis and encephalitis.

External ocular herpesvirus infections in immunodeficiency

Infections of the eye with members of the herpes family of viruses (e.g. HSV, CMV, VZV) are frequent manifestations of acquired and inherited defects in cell mediated immunity. Herpesvirus infections in the immunocompromised may reflect frequent viral reactivation from the latent state, as well as extensive productive infection of ocular structures following reactivation or primary infection. A review of experimental and clinical studies of both acquired and inherited immune dysfunction implicates specific immune mechanisms influencing the establishment of latency, viral reactivation and the control of active viral replication in ocular tissues.