Bilateral herpes simplex keratitis in a patient with graft-vs-host disease

Infections in Allogeneic Stem Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become a widely used modality of therapy for a variety of malignant and nonmalignant diseases. Despite advances in pharmacotherapy and transplantation techniques, infection remains one of the most severe and frequently encountered complications of allo-HSCT.

This chapter will address the risk factors for development of infection following allo-HSCT, including those related to the host, the conditioning regimen, and the graft, as well as the timing of opportunistic infections after allo-HSCT. The most common bacterial, viral, fungal, and parasitic infections, as well as issues surrounding their diagnostics and treatment, will be discussed. Finally, this chapter will address vaccination and other preventative strategies to be utilized when caring for patients undergoing allo-HSCT.

Bilateral herpes simplex keratitis in a patient with chronic graft-versus-host disease

Purpose

To describe a case of bilateral herpes simplex keratitis accompanying chronic graft-versus-host disease (GVHD).

Design

Observational case report.

Case report

An 11-year-old boy with myelocytic leukemia underwent allogeneic bone marrow transplantation. He developed symptoms of the skin, eyes, and mouth, and lip biopsy indicated chronic GVHD. Persistent keratitis with corneal filaments and neovascularization was noted in both eyes. Sodium hyaluronate, autoserum, and 0.1% fluorometholone eyedrops were instilled for approximately 2 years to treat this keratitis, and there were no other ocular changes. Bilateral herpes simplex keratitis developed with geographic ulcers after topical betamethasone therapy, but responded to acyclovir ointment.

Conclusions

Herpes keratitis should be considered in the differential diagnosis of bilateral keratitis in patients with reduced immunocompetence. During the course of chronic GVHD, corneal herpes may occur, so ocular treatment with topical corticosteroids should be managed by an ophthalmologist to monitor sight-threatening conditions such as corneal herpes.

Bilateral herpes simplex keratitis with unilateral secondary bacterial keratitis and corneal perforation in a patient with pityriasis rubra pilaris

PURPOSE

To report a case of bilateral herpes simplex keratitis with unilateral secondary bacterial keratitis resulting in corneal perforation in a patient with pityriasis rubra pilaris.

METHODS

Case report.

RESULTS

A 77-year-old female with pityriasis rubra pilaris was referred for a perforated corneal ulcer of the left eye. Cultures were positive in both eyes for Herpes simplex and in the left eye for Pseudomonas fluorescens and Staphylococcus aureus A microbiological cure was obtained with a combination of tectonic keratoplasty, fortified topical antibiotics, and systemic acyclovir.

CONCLUSIONS

Pityriasis rubra pilaris is a rare, inflammatory dermatologic disease that may predispose patients to bilateral Herpes simplex keratitis, secondary bacterial superinfection, and a tendency toward rapid stromal ulceration with risk of perforation.

Herpes simplex virus epidemiology and ocular importance

PURPOSE

To review the changing epidemiology of herpes simplex disease and correlate it with the epidemiology of ocular herpes simplex disease.

METHOD

A review of pertinent reports in the world literature about the epidemiology of herpes simplex and specifically about ocular herpes simplex.

RESULTS

In developed countries, many individuals are reaching adolescence and adulthood without prior herpesvirus infection. Herpes simplex genital infection is increasing at a rapid rate in sexually active adolescents and adults, with about one in six adults now infected in the United States. Similar statistics are confirmatory worldwide in developed countries. Active herpes simplex infection is a risk factor for acquisition of human immunodeficiency virus. The Herpetic Eye Disease Study, as well as prior studies from Moorfields Eye Hospital and the Mayo Clinic in Rochester, Minnesota, provides us with the epidemiology of ocular herpes simplex. Recent studies suggest an older age of onset and perhaps overall more severe ocular disease as compared with the older literature.

CONCLUSIONS

Herpes simplex is a significant health concern at present with genital infections increasing in epidemic proportions. This is also reflected in a rise in the incidence of neonatal herpes. Herpes simplex virus type 1 (HSV-1) infection is being acquired for the first time in an older age group. A significant and increasing proportion of genital herpes is caused by HSV-1. Serologic studies are no longer as useful in distinguishing orofacial herpes from genital herpes. More acute retinal necrosis syndrome cases are associated with HSV-2. Speculation about the future of ocular herpes is made based on this changing epidemiology.