Association of varicella zoster dermatitis with acute retinal necrosis syndrome

Advances in the microbiological diagnosis of herpetic retinitis

Viral retinitis associated with herpesvirus is one of the most severe forms of uveitis and is a potentially sight-threatening ophthalmologic disease. The prognosis is poor and a rapid and aggressive management is necessary to improve the visual and sometimes vital prognosis of these patients. The treatments used are not without side effects, while many differential diagnoses exist, such as toxoplasmic retinochoroiditis, syphilitic retinitis, endogenous endophthalmitis and intraocular lymphoma. Causatives viruses are herpes simplex virus, varicella-zoster virus, and cytomegalovirus, which require rapid detection in ocular fluid, mainly aqueous humor. However, only a small amount of intraocular fluid is available for analysis. Advances in microbiological diagnostic techniques therefore were key factors in improving the management of these diseases. Historically, the diagnosis was based on immunological tests but more recently advances in molecular biology, in particular polymerase chain reaction, have played a crucial role to obtain a reliable and rapid diagnosis of viral retinitis associated with herpesvirus, as discussed in this review.

Clinical course of von Szily reaction: Case report and comprehensive review of the literature

Purpose

To describe a rare case of von Szily reaction (VSR) accompanied by a comprehensive review of the literature.

Observations

A 57-year-old woman with herpes zoster ophthalmicus (HZO) associated with ipsilateral sectoral scleritis and anterior uveitis (sclerouveitis) subsequently developed contralateral necrotizing retinitis, leading to a diagnosis of VSR. A literature review revealed 10 additional cases of VSR. The full VSR cohort of 11 subjects included six women and five men, had a median age of 39 years (range 21–78 years), and most presented with HZO (n = 7, 63.6%), often associated with either ipsilateral anterior uveitis (n = 5; 45.5%) or keratitis (n = 4; 36.4%). All 11 cases developed necrotizing retinitis in the fellow eye, at a median of six weeks following onset in the sentinel eye. The most frequently implicated agent was varicella zoster virus (VZV; n = 8, 72.7%). A high proportion of the eight patients with VZV-associated VSR were identified as having increased risk of VZV reactivation, including age of 50 years or greater (n = 5, 62.5%), an underlying malignancy (n = 3, 37.5%), and/or use of immunosuppressive medication (n = 2, 25.0%).

Conclusion

This was the first reported case of VSR presenting as HZO-associated with sclerouveitis. A comprehensive literature review revealed that most previously reported cases presented with HZO associated with isolated anterior uveitis and/or keratitis, and that all reported cases of VSR developed necrotizing retinitis in the fellow eye, typically within two months of initial presentation. Patients with VZV-associated VSR often had known risk factors for VZV reactivation.

Combined central retinal artery and vein occlusion with optic perineuritis following herpes zoster dermatitis in an immunocompetent child

A 15-year-old healthy boy developed acute, rapidly progressing visual loss in left eye following herpes zoster dermatitis, with a combined central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO), along with optic perineuritis. Laboratory tests were negative. Despite an empirical, intensive antiviral treatment with systemic corticosteroids, and vision could not be restored in the affected eye. Herpes zoster dermatitis, in an immunocompetent individual, may be associated with a combined CRAO and CRVO along with optic perineuritis, leading to profound visual loss.

Two patients with the von Szily reaction: herpetic keratitis and contralateral retinal necrosis

PURPOSE

To present two patients with prior unilateral, herpetic keratitis who developed acute retinal necrosis (ARN) in the contralateral eye. These cases have noticeable similarities to the von Szily reaction. This describes the development of a contralateral retinitis subsequent to an anterior chamber injection of herpes simplex virus (HSV).

DESIGN

Interventional case series.

METHODS

Retrospective chart and literature review.

RESULTS

The first patient had neonatally acquired herpetic keratitis and developed ARN at age 21. Polymerase chain reaction of a vitreous biopsy detected HSV type-2 (HSV-2). The second patient was clinically diagnosed with ARN contralateral to varicella zoster keratitis. A detailed literature search located seven prior case reports with a von Szily reaction. These resembled our two cases except none had HSV-2 or years of latency from keratitis to retinitis.

CONCLUSIONS

Clinicians need to be cognizant of the von Szily reaction.

Ocular Findings in Japanese Patients with Varicella-Zoster Virus Infection

PURPOSE

To examine ocular findings in Japanese patients with varicella, herpes zoster ophthalmicus, and acute retinal necrosis.

METHODS

A retrospective study was conducted. Information on the ocular, cutaneous, systemic, and virologic findings on pediatric and adult patients was obtained from medical records.

RESULTS

A total of 77 (45 male and 32 female) patients were enrolled in the study: 4 children had varicella, 68 adults had herpes zoster ophthalmicus, and 5 adults had acute retinal necrosis. Children with varicella had eruptions on the eyelid. Patients with herpes zoster ophthalmicus had eruptions, conjunctivitis, keratitis, iridocyclitis, and other findings. Patients with acute retinal necrosis had intracameral cells and retinal lesions. Some patients with herpes zoster ophthalmicus had malignancy, type 2 diabetes mellitus, or other disease. One pregnant woman developed acute retinal necrosis shortly after varicella infection. A total of 48% of patients with negative Hutchinson sign had ocular lesions, while all patients with positive sign showed ocular lesions. Patients with varicella and herpes zoster ophthalmicus had good visual acuity at the last visit. Some patients with acute retinal necrosis had poor visual acuity at the last visit.

CONCLUSIONS

Patients with varicella, herpes zoster ophthalmicus, and acute retinal necrosis had several ocular complications. Some patients with acute retinal necrosis had poor visual outcomes. Ophthalmologists should be aware that acute retinal necrosis may develop shortly after varicella infection.

Unilateral varicella zoster virus ophthalmicus and contralateral acute retinal necrosis

We report two patients who developed varicella zoster virus (VZV) ophthalmicus complicated by ipsilateral keratouveitis, and within 4 weeks developed acute retinal necrosis (ARN) in the contralateral eye. The ipsilateral retina was spared in each case. One patient had systemic lupus erythematosus (SLE) and the other Hodgkin's disease. Both patients were in remission at the time of presentation.

Clinical manifestations of varicella-zoster virus infection

Infections by VZV, the virus that causes chickenpox and herpes zoster, usually are diagnosed by the classic clinical presentations. In immunocompromised patients, however, the atypical presentation can make the diagnosis more challenging. Although varicella typically follows an uncomplicated course in children, adults and immunocompromised patients can develop complications involving several organs; some complications may be fatal. Prevention of disease with the vaccine is ideal. When varicella or zoster infection does occur, proper treatment should be initiated, depending on the age and immune status of the patient.

Advances in diagnosis and management of herpetic uveitis

Herpetic eye disease is common and is frequently associated with intraocular inflammation or uveitis. Despite recent advances in measuring anti-herpes virus antibodies and viral DNA in ocular fluids, diagnosis remains largely clinical. The two more common syndromes include anterior uveitis, often associated with keratitis, and the acute retinal necrosis (ARN) syndrome. Treatment is complex and requires careful monitoring to provide the appropriate balance of antiviral medication and corticosteroids. Long-term prophylaxis with oral antiviral agents may be required in selected patients to help prevent the vision-compromising complications associated with recurrences.

Viral causes of the acute retinal necrosis syndrome

PURPOSE

The primary goal of this study was to determine the viral cause of the acute retinal necrosis syndrome in 28 patients (30 eyes). A secondary goal was to investigate possible associations between viral cause and patient age, and viral cause and central nervous system disease.

METHODS

A retrospective case series in which we reviewed the laboratory results and clinical histories of 28 patients (30 eyes) diagnosed with acute retinal necrosis syndrome, from whom vitreous or aqueous specimens were received, for diagnostic evaluation using previously described polymerase chain reaction-based assays.

RESULTS

Varicella-zoster virus, herpes simplex virus, and cytomegalovirus (CMV) DNA were detected in aqueous and/or vitreous specimens from 27 of 28 patients (29 of 30 eyes with a clinical history of acute retinal necrosis syndrome). No sample was positive for DNA from more than one virus. Varicella-zoster virus DNA was detected in 13 patients (15 eyes). Median age was 57 years. Herpes simplex virus type 1 DNA was detected in seven patients (seven eyes). Median age was 47 years. Six of these patients had a history of herpes simplex virus encephalitis. Herpes simplex virus type 2 DNA was detected in six patients (six eyes). Median age was 20 years. Three of these patients had a likely history of meningitis. Cytomegalovirus DNA was detected in one patient who was immunosuppressed iatrogenically. No viral DNA was detected in one patient from whom a sample was taken after 6 weeks of acyclovir therapy.

CONCLUSIONS

The data suggest that varicella-zoster virus or herpes simplex virus type 1 cause acute retinal necrosis syndrome in patients older than 25 years, whereas herpes simplex virus type 2 causes acute retinal necrosis in patients younger than 25 years. A history of central nervous system infection in a patient with acute retinal necrosis syndrome suggests that herpes simplex virus is likely to be the viral cause.

Necrotising herpetic retinopathy in patients with advance HIV disease

OBJECTIVES

To describe the presenting features, clinical and laboratory diagnosis, response to treatment, and outcome of necrotising herpetic retinopathy (NHR) in HIV infected patients.

METHODS

Retrospective case records/laboratory data review of five HIV infected patients presenting to the specialist HIV/AIDS unit at UCL Hospitals, London from April 1994 to August 1996 with a clinical diagnosis of NHR.

RESULTS

All patients had advanced HIV disease with a median CD4 count of 20.10(6)/1. Three patients had cutaneous varicella zoster virus (VZV) infection within the preceding 8 weeks. All had uniocular loss of visual acuity; one also had headache and another ocular pain. All had typical retinal appearances. VZV DNA was detected in cerebrospinal fluid of four patients (and in vitreous fluid of one of the four) and in vitreous fluid of one other. One patient refused therapy and rapidly became blind. Four patients received intravenous foscarnet with intravenous aciclovir for 6 weeks: three subsequently received oral famciclovir and one oral valaciclovir; two patients also had intravitreal injections of foscarnet. In none of the four did treatment bring about improvement in visual acuity, but in all four visual loss from retinitis was halted.

CONCLUSIONS

NHR occurs in HIV infected patients with advanced HIV disease and is strongly associated with evidence of VZV infection. With aggressive use of antiviral drugs the outcome is not uniformly poor.

Association of herpes zoster ophthalmicus with acquired immunodeficiency syndrome and acute retinal necrosis

We conducted a review to investigate the prevalence of human immunodeficiency virus (HIV), or acquired immunodeficiency syndrome (AIDS), in patients with herpes zoster ophthalmicus, as well as the incidence of acute retinal necrosis after herpes zoster ophthalmicus. All charts of patients seen at our institution between 1987 and 1992 with a primary diagnosis of herpes zoster ophthalmicus were reviewed. Of 112 patients with herpes zoster ophthalmicus, 29 (26%) had HIV or AIDS. All these patients were younger than 50 years at the time of diagnosis. Five of 29 (17%) immunocompromised patients had acute retinal necrosis after herpes zoster ophthalmicus. No acute retinal necrosis was identified in the nonimmunocompromised patients after herpes zoster ophthalmicus. We recommend that all patients younger than 50 years who have herpes zoster ophthalmicus at initial examination be tested for HIV. Additionally, HIV-infected patients should be monitored closely after herpes zoster ophthalmicus for development of acute retinal necrosis. Long-term oral prophylactic as well as initial high-dose intravenous acyclovir may be appropriate in HIV-infected individuals with herpes zoster.

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.

Systemic antiviral drugs used in ophthalmology

Over the past two decades, the recognition of viral enzymes and proteins that can serve as molecular targets of drugs has revolutionized the treatment of viral infections. Beginning with acyclovir, a number of systemically administered agents which are both relatively safe and effective for the treatment of herpetic infections and human immunodeficiency virus (HIV) infections have become widely available. Because of increased numbers of herpes virus infections, as well as the rising epidemic of HIV infections, the ophthalmologist is, more likely than ever before to be involved in the treatment of severe and frequent ocular infections caused by herpes viruses. In addition, the acute retinal necrosis (ARN) syndrome has been demonstrated to be caused by herpes viruses and a once rare retinal infection caused by cytomegalovirus is common in patients with the acquired immunodeficiency syndrome (AIDS). In this article, four systemic antiviral drugs (Vidarabine, Acyclovir, Ganciclovir, and Foscarnet) that have demonstrated usefulness in the treatment of ophthalmic disease are reviewed in detail with regard to their mechanisms, applications, effectiveness, and side effects.

Herpesvirus antibody levels in the etiologic diagnosis of the acute retinal necrosis syndrome

Quantitative antibody levels to three herpesviruses in acute and chronic sera from six patients with clinical signs of the acute retinal necrosis syndrome were consistent with a specific etiologic diagnosis only in the two cases associated with cutaneous herpes zoster. Available data on acute and convalescent antibody titers to herpes group viruses from these six patients in addition to data from 27 acute retinal necrosis cases from the literature disclosed that only 13 of the 33 patients (39%) had a diagnostic increase or decrease in herpes group viral antibody levels on serial sampling. Three patients had nondiagnostic changes in viral antibody levels despite positive vitreous cultures for herpesviruses. In contrast, a review of 25 cases from the literature with paired antiviral serum and intraocular fluid antibody levels suggested a more promising approach to the etiologic diagnosis of the acute retinal necrosis syndrome. By calculating the ratio of antiviral antibodies in intraocular fluid and serum, an etiologic diagnosis could be made in 12 of 14 (86%) of subacute and convalescent samples. The sensitivity of this method decreased to 72% (13 of 18) when fluids were obtained earlier in the course of the disease.

Chickenpox-associated acute retinal necrosis syndrome

Acute retinal necrosis (ARN) syndrome usually occurs as the result of secondary reactivation of latent, previously acquired, varicella-zoster or herpes simplex virus. The authors report four patients who developed a mild form of ARN within 1 month (5 to 28 days) after the onset of chickenpox. In contrast to typical cases of ARN, these cases were less severe, with retinitis limited to two quadrants or less (three patients), no retinal detachment (four patients), minimal vitreitis (four patients), and no loss of visual acuity (four patients). Thus, ARN may occur during the course of primary varicella-zoster infection.

Surgical management of retinal detachment associated with the acute retinal necrosis syndrome

We operated on nine eyes in eight patients with retinal detachment associated with acute retinal necrosis (ARN) syndrome. The patients were treated with scleral buckling, vitreoretinal surgery, or a combination of these treatments. Vitrectomised eyes underwent combinations of lensectomy, membrane dissection, scleral buckling, air-fluid exchange, endolaser photocoagulation, cryotherapy, and retinal tamponade with C3F8 gas or SF6 gas. Macular attachment was achieved in eight (89%) eyes. Vision improved in seven (78%) eyes, of which five (56%) achieved 20/200 or better vision. Three eyes that had received laser treatment posterior to areas of retinitis suffered retinal detachment despite this prophylactic treatment. Poor visual outcome resulted from viral infection of the optic nerve or macular involvement, macular hole formation, macular pucker, or hypotony.

Acute retinal necrosis syndrome

Acute retinal necrosis (ARN) is a rare syndrome with characteristic fundal appearances which can have devastating effects on vision. We present six cases (nine eyes) seen in the Medical Eye Unit of St Thomas's Hospital over the past six years and discuss the clinical features, aetiology, and management. Our findings support the present consensus that the condition is caused by varicella zoster virus (VZV) or herpes simplex virus (HSV). One of our patients, who was atypical in having common variable hypogammaglobulinaemia, had suffered a widespread zosteriform rash immediately prior to the onset of ARN, while another had suffered a herpes simplex uveomeningoencephalitis. All cases had characteristic confluent peripheral retinal necrosis, and three of the nine eyes developed retinal detachment. Retinal arteritis was a prominent and helpful diagnostic feature in one case. From combining all reports to date of this rare condition it is possible to conclude that ARN is unilateral in 65% of cases.

Diagnosis and management of the acute retinal necrosis (ARN) syndrome

The acute retinal necrosis (ARN) syndrome represents a specific pattern of clinical presentation for certain herpes virus infections in the posterior segment of the eye. The classically described triad of the ARN syndrome consists of (1) an arteritis and phlebitis of the retinal and choroidal vasculature, (2) a confluent, necrotizing retinitis that preferentially affects the peripheral retina, and (3) a moderate to severe vitritis. Anterior segment inflammation, optic neuritis, and late retinal detachment are also common features of this disorder. Definitive evidence now implicates at least two members of the herpes virus family; varicella zoster virus and herpes simplex virus as causative agents. This paper summarizes the clinical presentation, as well as the currently recommended treatment regimen for the ARN syndrome, highlighting recent advances that have resulted in a significant improvement in the visual prognosis for affected patients.

Evidence that precursor cytotoxic T cells mediate acute necrosis in HSV-1-infected retinas

Following uniocular anterior chamber injection of HSV-1 (KOS) in BALB/c and A/J mice, it is paradoxical that (a) acute retinal necrosis (ARN) develops only in the uninjected eyes, and (b) ARN occurs only in mice that are immunocompetent, event though these mice invariably display anterior chamber associated immune deviation (ACAID), wherein delayed hypersensitivity to HSV antigens is grossly impaired. Previous studies have revealed that ARN develops only if the titer of infectious virus in the contralateral eye exceeds 4 Log10 PFU, indicating that virus infection is essential to ARN. However, HSV-1 titers in contralateral eyes of similarly infected athymic mice also exceed 4 Log10 PFU, even though these mice never develop ARN - implying that virus alone is insufficient to cause retinal cell destruction. In an effort to define the pathogenic immune component of ARN, we have evaluated in vitro viral antigen-specific T cell responses in mice with ARN and ACAID. We found that T cells, harvested from draining ipsilateral cervical lymph nodes and contrateral eye proliferate in response to viral antigens, express IL-2 receptors, and include HSV-1-specific precursor cytotoxic T cells (pTc), but not direct cytotoxic T cells (Tc). Since the time of appearance of HSV-specific pTc in the contralateral eye coincides with entry of infectious virus into that eye, and since their mutual appearance heralds the onset of retinal necrosis, we conclude that destruction of the retina is initiated by virus-specific cytotoxic T cells that lyse HSV-infected retinal cells.

Herpes simplex virus type 1. A cause of the acute retinal necrosis syndrome

The authors have isolated herpes simplex virus type 1 (HSV-1) from the vitreous of two patients with acute retinal necrosis. Clinical and laboratory data suggest that one case represented a primary HSV-1 infection, whereas the other case appeared to be a recurrent HSV-1 infection. In the primary case, changes on magnetic resonance imaging (MRI) suggest spread of the virus posteriorly to both optic tracts and the lateral geniculate ganglia. This case shares many features with the "von Szily" experimental model for HSV retinitis in the mouse.

The spectrum of optic nerve disease in human immunodeficiency virus infection

We studied four patients with HIV-associated optic neuropathies. One had syphilitic optic perineuritis, which responded promptly and completely to penicillin therapy. The second had cytomegalovirus papillitis and visual acuity subsequently deteriorated to no light perception. The third showed varicella zoster optic neuritis, which improved after intravenous acyclovir treatment. The fourth patient developed cryptococcal retrobulbar neuritis and died shortly thereafter. Optic neuropathy was among the initial symptoms of HIV infection in two of the four cases.

Acute retinal necrosis syndrome presenting with papillitis and arcuate neuroretinitis

Acute retinal necrosis (ARN) syndrome is a diffuse uveitis characterized by a peripheral necrotizing retinitis and retinal vasculitis. The authors document and discuss a case of ARN syndrome that initially presented with remarkable changes in the peripapillary retinal nerve fiber layer that they have termed arcuate neuroretinitis. These changes consisted of a well-defined arcuate band of retinitis paralleling the course of a parafoveal nerve fiber bundle. Evaluation of serial serum antibody titers suggests HSV-2 as a possible causative agent in this unique presentation of ARN syndrome.