Mooren's corneal ulcers and hepatitis C virus infection

Corneal wound healing

The corneal wound healing response is typically initiated by injuries to the epithelium and/or endothelium that may also involve the stroma. However, it can also be triggered by immune or infectious processes that enter the stroma via the limbal blood vessels. For mild injuries or infections, such as epithelial abrasions or mild controlled microbial infections, limited keratocyte apoptosis occurs and the epithelium or endothelium regenerates, the epithelial basement membrane (EBM) and/or Descemet's basement membrane (DBM) is repaired, and keratocyte- or fibrocyte-derived myofibroblast precursors either undergo apoptosis or revert to the parent cell types. For more severe injuries with extensive damage to EBM and/or DBM, delayed regeneration of the basement membranes leads to ongoing penetration of the pro-fibrotic cytokines transforming growth factor (TGF) β1, TGFβ2 and platelet-derived growth factor (PDGF) that drive the development of mature alpha-smooth muscle actin (SMA)+ myofibroblasts that secrete large amounts of disordered extracellular matrix (ECM) components to produce scarring stromal fibrosis. Fibrosis is dynamic with ongoing mitosis and development of SMA + myofibroblasts and continued autocrine-or paracrine interleukin (IL)-1-mediated apoptosis of myofibroblasts and their precursors. Eventual repair of the EBM and/or DBM can lead to at least partial resolution of scarring fibrosis.

Case report: bilateral Mooren ulcer in association with hepatitis C

BACKGROUND

Mooren ulcer has been considered as an idiopathic autoimmune keratitis. However, it has been in some cases suggested to be associated with hepatitis C, although the evidence is very vague.

CASE PRESENTATION

We present a case of a man who was diagnosed with a primary Mooren ulcer in his right eye. The eye became blind despite of intensive treatment with local medications and extensive surgical procedures. After 10 years, the patient was diagnosed with the same disease, now in his left, previously healthy eye. There was no history that would suggest a secondary Mooren ulcer, but a chronic hepatitis C infection was detected. Treatment was targeted against hepatitis C (ribavirin and interferon) in addition to immunosuppressive medical and surgical treatment which resulted in a full and more than 6 years lasting remission of the disease.

CONCLUSIONS

Whether the immunomodulatory and immunosuppressive medication against hepatitis C was the key reason for the good results in the treatment of the second eye, remains elusive. The causality of hepatitis C with respect to the pathogenesis of Mooren ulcer on this patient remains open, but should be considered as one of the possible etiological factors of the disease.

Systemic manifestations of hepatitis C infection

Chronic hepatitis C (HCV) is a common infection affecting 185 million people worldwide. The most common manifestation of chronic HCV is progressive liver fibrosis, cirrhosis, liver failure and hepatocellular carcinoma. However, several systemic manifestations of HCV have been recognized and reported in the literature. The purpose of this review is to assimilate published literature based on evidence to categorize these extrahepatic manifestations with the likelihood of a causal association with HCV. Exciting recent developments have resulted in simple all oral interferon-free highly effective therapy for HCV. However, this treatment is also expensive and less accessible to most affected individuals as treatment recommendations are based on stage of liver fibrosis. Expanding the scope of HCV therapy to those with extrahepatic manifestations beyond what is currently recommended will significantly reduce the morbidity and mortality in this aging population.

Extrahepatic manifestations of hepatitis C infection: navigating CHASM

This article describes the importance of extrahepatic systemic manifestations of chronic hepatitis C virus (HCV) infection. While most HCV literature focuses on liver injury and fibrosis progression, a spectrum of systemic disease processes, collectively called C hepatitis-associated systemic manifestations (CHASMs), are present in a high proportion of infected persons. These include thyroid disease (Hashimoto's thyroiditis, Graves disease, and thyroid cancer), cardiovascular disease (atherosclerosis, carotid artery disease, and coronary artery disease), renal disease (MPGN and glomerulosclerosis), eye disease (Mooren's ulcers and sicca syndrome), skin disease (PCT, vasculitis, and lichen planus), lymphomas (NHL and splenic T-cell), and diabetes. Mechanistic understanding of how HCV leads to CHASM processes could lead to development of new interventions. The role of early HCV treatment and cure may result in preventive strategies for a variety of complex disease states. Key Points • Systemic extrahepatic complications of HCV comprise a spectrum of disease states in many organs and systems.• Effective treatment of HCV may reduce or eliminate some but not all of these systemic complications.• Further research into early treatment intervention as a prevention strategy for systemic disease is warranted.

Hepatitis C and ocular surface disease

PURPOSE

To assess the frequency of changes in the ocular surface and the presence of hepatitis C virus (HCV) in tear samples of patients with chronic HCV infection.

DESIGN

Prospective, nonrandomized, clinical, interdisciplinary, single-center study.

METHODS

Seventy-one patients with previously untreated chronic HCV infection and a control group consisting of 66 patients without systemic HCV infection were enrolled in the trial. The patients with HCV infection were screened for ocular symptoms, visual acuity, and ocular changes. Tear production was measured by the Jones test. Conjunctival impression cytologic analysis was performed. The presence of HCV ribonucleic acid (RNA) in tear and blood samples was determined by quantitative polymerase chain reaction.

RESULTS

On examination, systemic HCV infection was present for a median of 30 months. Fifty percent of all HCV patients showed a decrease in tear production measured by the Jones test. Apart from epithelial changes related to dry eye syndrome in 12 patients, two patients presented mild peripheral corneal thinning. Polymerase chain reaction analysis detected HCV RNA in five (10%) of 52 tear samples. HCV RNA levels in tear samples (mean, 1.0 x 10(4) copies/ml) were considerably lower than in blood samples (mean, 5.3 x 10(5) copies/ml).

CONCLUSIONS

Dry eye syndrome is the most frequently observed ocular feature in HCV infection. Patients with HCV infection (age range, 21 to 60 years) compared with the controls had a significant lower tear production (P = .05). The presence of HCV RNA in 10% of tear samples emphasizes the potential risk of viral transmission through tears.

Chronic hepatitis C virus infection is not associated with Mooren's ulcer

AIM

To investigate the association between chronic hepatitis C virus (HCV) infection and Mooren's ulcer.

METHODS

Eight patients from different parts of China who were diagnosed with Mooren's ulcer at the Zhongshan Ophthalmic Center, Guangzhou (China) were screened for chronic HCV infection. Mooren's ulcer was diagnosed by the typical ulcer morphology, detailed case history, physical examination, and comprehensive laboratory tests. All patients had serological screening for HCV infection.

RESULTS

Six male and two female patients were enrolled in the study. Their ages ranged from 31 to 65 years (mean 43.6+/-13.7). None of them was reported to have any clinical evidence of chronic HCV infection before enrolment and all were negative for HCV serology.

CONCLUSION

There was no association between chronic HCV infection and Mooren's ulcer in this limited case series study.

[A case report of a recurrence of Mooren's ulcer after cataract surgery]

We report the case of Mooren's ulcer recurrence after uncomplicated cataract surgery in a 61-year-old woman. This cataract developed because of repetitive inflammation of the anterior chamber and corticotherapy. Local and general corticotherapy with cyclosporin 2% drops was started in association with an anterior lamellar graft and a conjunctival recession due to a preperforation condition. Secondarily cyclophosphamide was necessary to control recurrence with a good anatomic result and an increase in visual acuity. The case updates physiopathologic and diagnostic data on this rare limbic autoimmune ulcerative disease. The diagnosis was made by histology and the dosage of specific autoantibodies against cornea. The prevention of recurrence after surgery requires a long clinical quiescent period, minimally invasive surgery long after inflammation has subsided, and a gradual tapering of corticotherapy over several weeks.

Oculo-renal disorders in infectious diseases

BACKGROUND

The aim of this article is to review the potential ocular and renal disorders in infectious diseases to which humans are susceptible and to determine prevalence of these diseases.

METHODS

Published cases of oculo-renal disorders associated with various infectious diseases were collected from the international literature by searching the MEDLINE database (PUBMED 1970-2004) for original reports and review articles published in English. Citations from papers retrieved were screened and retrieved papers were evaluated.

RESULTS

Based on the screened data, we propose a practical, structure-oriented checklist of such lesions divided into bacterial, viral, parasital, and fugal infections.

CONCLUSION

The oculorenal manifestations of infectious diseases may be flagrant or subtle. Awareness of the signs and symptoms of infections allows early recognition and prompt, appropriate management. The clinical presentation and relative frequency of those manifestations are reviewed.

Antiviral therapy: role in the management of extrahepatic diseases

This article considers the extrahepatic manifestations associated with HBV and HCV infection, the strength of the evidence for the association, potential pathological mechanisms, and evidence based therapeutic recommendations. As many of these extra hepatic conditions are uncommon, published reports have been largely uncontrolled or anecdotal.

Hepatitis C virus-associated keratitis

AIM

To study the association between chronic hepatitis C virus (HCV) and Mooren's type keratitis.

METHOD

A total of 50 patients with chronic HCV were screened for any evidence of corneal ulceration. Detailed ocular examination was conducted by slit-lamp biomicroscopy. Patients with history of trauma to the eye or previous herpetic keratitis were excluded from the study.

RESULTS

There were 37 males and 13 females. The age of the patients ranged from 10 to 70 years. There was no evidence of Mooren's ulcer in any of our patients.

CONCLUSION

No association between chronic HCV and Mooren's ulcer was found in our study. Screening therefore in such cases is not necessary.

[Extrahepatic manifestations of hepatitis C virus infection]

<zakljucak> Hepatitis C virusna infekcija je zaista povezana sa sirokim spektrom ekstrahepatickih sindroma. Neke bolesti su sigurno povezane sa HCV infekcijom (krioglobulinemija, kasna kozna porfirija, membranoproliferativni glomerulo-nefritis), za neke postoji velika verovatnoca (autoimunske bolesti stitaste zlezde, autoimunska trombocitopenija, limfomi, secerna bolest neuropatije, artritis, lihen planus, nodozni poliarteritis, sijaloedenitis sindrom fibromialgije) dok se za neke bolesti ostavlja mogucnost da se radi o slucajnoj udruzenosti za sto su potrebna nova istrazivanja.

Prevalence of seropositivity for hepatitis C virus in cataract patients and the general population

PURPOSE

To investigate the epidemiologic relationship between hepatitis C virus (HCV) infection and cataract.

SETTING

Yoshida Eye Clinic, Fukuoka, Japan.

METHODS

This study included 492 patients with age-related cataract and 2624 controls who had a municipal mass health screening. All subjects were 60 years or older and inhabitants of Chikugo City (population 45000), Fukuoka, Japan. Each subject was serologically tested for HCV using the third-generation enzyme immunoassay. Seropositivity was compared in subgroups consisting of patients by decade; that is 60 to 69 years of age, 70 to 79 years of age, and 80 to 90 years of age.

RESULTS

The prevalence of HCV in the cataract group and health-screening (control) group was 18.3% and 7.1%, respectively, in the 60- to -69 year subgroup; 17.8% and 6.6%, respectively, in the 70- to 79-year subgroup; and 15.1% and 3.7%, respectively, in the 80- to 90-year subgroup. In each subgroup, the prevalence of HCV was significantly higher in the cataract group than in the control group (P <.01, chi-square test). In the cataract group, the HCV seropositive and seronegative groups did not differ significantly in the prevalence of hepatitis B virus (P =.548, Fisher exact probability test).

CONCLUSIONS

Patients with age-related cataract had significantly higher seropositivity for HCV than an age-matched general population. This suggests that HCV infection may play a role in the development and/or progression of cataract.

Hepatitis C and the skin

Hepatitis C is an important and common cause of chronic hepatitis and cirrhosis. Cutaneous manifestations are often the first signs of infection. Dermatologists must be aware of these manifestations, because early diagnosis is the best treatment. HCV Ab by ELISA should be ordered in patients with LCV-urticarial vasculitis, cryoglobulinemia, lichen planus, Sjögren's syndrome, unexplained pruritus, PCT, PAN, chronic urticaria, patients starting methotrexate, unexplained pruritus, and any patient initiating therapy with a potentially hepatotoxic drug.

Whipple disease. Clinical review of 52 cases. The SNFMI Research Group on Whipple Disease. Société Nationale Française de Médecine Interne

Whipple disease is a rare, multiorgan disease with prominent intestinal manifestations. We report a retrospective clinical study of 52 patients recruited in various parts of France from 1967 to 1994. Seventy-three percent of the patients were male. Clinical manifestations preceding the diagnosis were articular for 35 patients (67%), digestive for 8 patients (15%), general for 7 patients (14%), and neurologic for 2 patients (4%). At a later stage of the disease, 44 patients (85%) presented diarrhea, weight loss, and malabsorption, while 8 patients (15%) did not show any gastrointestinal symptom throughout the development of the disease. Forty-three patients (83%) presented arthralgia or arthritis, and 11 (21%) had prominent neurologic symptoms. In addition, cardiovascular symptoms were present in 9 patients (17%); mucocutaneous symptoms, in 9 patients (17%); pleuropulmonary symptoms, in 7 patients (13%); and ophthalmologic symptoms, in 5 patients (10%). All patients but 1 were given a positive diagnosis on histopathologic criteria: jejunal biopsy for 46 patients (90%), lymph node biopsy for 3 patients (6%), brain biopsy for 1 patient (2%), postmortem jejunal and cerebral biopsy for 1 patient (2%). With treatment, the disease evolved favorably in 47 patients (90%), while 5 patients (10%) had unfavorable outcomes (2 deaths from neurologic involvement, 1 patient with chronic dementia, and 2 patients with digestive symptoms insensitive to antimicrobial therapy). Of the 41 patients initially treated successfully and whose treatment has been completed, clinical evolution after discontinuation of treatment was favorable in 34 cases (83%). Clinical relapses occurred in 7 patients. No relapse was observed after treatment by trimethoprim-sulfamethoxazole, alone or following a combination of penicillin and streptomycin, or after the combination of penicillin and streptomycin, whatever the oral follow-up treatment prescribed. The evolution of patients showing a relapse was favorable in all cases after reintroduction of antibiotic therapy. These results are discussed in the light of previously published series and case reports of Whipple disease. The diagnosis of the disease remains difficult at an early phase or when digestive symptoms are absent. It is noteworthy that proximal enteroscopy is sometimes misleading, considered normal on macroscopic examination and nonspecific on pathologic grounds. A normal erythrocyte sedimentation rate represents another pitfall. Histopathology is the key for positive and differential diagnosis, and may require multiple and repeated biopsies. Findings from molecular biology confirm the central role of an uncultured Gram-positive bacillus which was named in 1992 Tropheryma whippelii. A recent report suggests that polymerase chain reaction (PCR) analysis of peripheral blood might allow the diagnosis of Whipple disease in some cases. However, immunologic or cellular parameters such as macrophagic function may play an important, although not clearly elucidated, role in the pathogeny of the disease. Trimethoprim-sulfamethoxazole should be considered the antimicrobial agent of choice in the treatment of Whipple disease, minimizing the risk of cerebral involvement and relapses.

Nonhepatic manifestations and combined diseases in HCV infection

Infection with hepatitis C virus (HCV) may affect not only the liver but also various nonhepatic tissues and organs and may combine with many etiologically unrelated diseases and morbid conditions. Numerous nonhepatic manifestations in HCV infection have been previously reported. For some (eg, cryoglobulinemia), the association is well established. For others, such as sialadenitis and lichen planus, the association is probable (but not completely documented) and, for the remainder, the associations are weak. Extrahepatic manifestations may result from immunological mechanisms as well as virus invasion and replication in the affected extrahepatic tissues and organs. Thyroid abnormalities, primarily Hashimoto's disease, and isolated increases of anti-thyroid antibodies (ATPO) appear to be more frequent in chronic hepatitis C than B or D, with high ATPO titers clustering mainly among females. Interferon-alpha (IFN-alpha) therapy is associated with development of thyroid dysfunction in 5.5-12.9% of patients, usually exposing preexisting subclinical thyroid abnormalities. Mixed cryoglobulinemia (MC) is commonly found (36-45%) in patients with chronic HCV infection; however, only in a minority of cases does it become clinically manifested as systemic vasculitis with purpura, neuropathy, or Raynaud's phenomenon. In a number of patients, MC may terminate in non-Hodgkin's B-cell lymphoma. Treatment of these lymphoproliferative disorders with IFN-alpha is advocated. Idiopathic thrombocytopenia is now recognized more frequently in association with chronic HCV infection and is usually aggravated by IFN-alpha therapy. Patients with porphyria cutanea tarda (PCT) have demonstrated serological markers of HCV infection in 62-82% of cases. The usefulness of IFN-alpha in PCT remains to be demonstrated. Lichen planus has also been found in association with chronic HCV infection, particularly when severe or affecting the oral cavity. Other nonhepatic manifestations have also been reported in HCV infection such as diabetes, corneal ulceration, uveitis, and sialadenitis. These manifestations deserve further study and documentation. Finally, markers of autoimmunity occur with high frequency in chronic HCV infection; however, combination with the classical syndrome of autoimmune hepatitis is rare. In the presence of various autoantibodies, the clinical features of chronic hepatitis C do not appear to be modified and, contrary to general perception, IFN-alpha therapy within randomized controlled trials should not be withheld since the response rate to IFN-alpha does not appear to differ in the presence or absence of low titers of these markers.

Hepatitis C virus in body fluids after liver transplantation

Recurrence of hepatitis C virus (HCV) after liver transplantation is common and is associated with high blood levels of HCV RNA. Higher blood levels of HCV may promote body fluid expression of the virus. We tested 152 body fluid specimens from 33 patients with chronic hepatitis C, 21 of whom had undergone prior liver transplantation. All patients had hepatitis C viremia, as determined by a reverse-transcription polymerase chain reaction (PCR) to the 5' noncoding region. The virus was quantitated in serum by the branched chain DNA assay (bDNA). Body fluids (33 sputum, 33 saliva, 33 urine, 32 tear, 9 vaginal, and 12 semen samples) were analyzed using PCR for HCV RNA. Serum HCV RNA by bDNA in the posttransplantation group was 255 +/- 229 x 10(5) compared with 50 +/- 56 x 10(5) eq/mL in the patients who did not undergo transplantation (P = .01). All urine, tear, and semen specimens were negative for HCV RNA. Five of 21 (24%) posttransplantation patients had detectable HCV RNA using PCR in oral secretions compared with 0 of 12 patients who did not undergo transplantation (not statistically significant). However, 5 of 11 patients with serum HCV RNA by bDNA results greater than 150 x 10(5) eq/mL had positive RNA in oral secretions compared to 0 of 22 patients with bDNA less than 150 x 10(5) eq/mL (P = .01). Posttransplantation patients were more likely to have bDNA levels exceeding 150 x 10(5) eq/mL (11 of 21 v 1 of 12, P = .03). Patients within the first year of transplantation were particularly prone to viral RNA levels exceeding 150 x 10(5) eq/mL (8 of 9 v 3 of 12, P = .01). We conclude that HCV RNA can occasionally be detected using PCR in oral secretions after liver transplantation. This is more likely during the first year posttransplantation when blood levels of HCV RNA often exceed 150 x 10(5) eq/mL by the branched chain DNA assay. Whether or not these observations represent an increased risk of transmission of infection during the early posttransplantation period is not certain.

Mooren-type hepatitis C virus-associated corneal ulceration

BACKGROUND

Two patients with bilateral Mooren-type ulcers had underlying chronic hepatitis C virus (HCV) infection. Both patients also had chronic, pruritic dermatitis, which in one patient was diagnosed as hidradenitis suppurativa.

METHODS

Serum from the first patient and serum, conjunctiva, and liver from the second patient were analyzed for HCV genomic RNA using the reverse transcriptase-polymerase chain reaction. Serum anti-HCV antibodies were monitored with a commercially available second-generation test. Liver and conjunctival biopsies were evaluated histopathologically.

RESULTS

Liver biopsy showed severe hepatitis in the first patient, but normal liver tissue in the second. Hepatitis C virus genomic RNA was detected in the serum of both patients. In the first patient, the virus was detected 4 months after completion of interferon alfa-2b treatment for chronic active hepatitis. In the second patient, HCV genomic RNA was detected in serum, but not in conjunctiva or liver tissue. Hepatitis C virus could not be detected in the serum of the second patient after 2 weeks of interferon alfa-2b treatment. Both patients had serum anti-HCV antibodies. In case 1, there was a marked improvement in the corneal disease during and after 6 months of interferon alfa-2b treatment for chronic active hepatitis that paralleled a return of serum liver enzyme levels to the normal range. In the second patient, the corneal disease improved after 6 weeks of interferon alfa-2b treatment, but abruptly worsened when the patient discontinued therapy. The corneal disease improved again after interferon alfa-2b was reinstituted.

CONCLUSIONS

Chronic HCV virus infection is associated with Mooren-type peripheral ulcerative keratitis. All patients with Mooren-type ulcers should be tested for evidence of HCV infection in consultation with a liver specialist. Even when improvement is obtained with interferon alfa-2b treatment, however, continued follow-up is important because relapse is common and repeat treatment may be effective.