A 9 Year-Old Girl with Herpes Simplex Virus Type 2 Acute Retinal Necrosis Treated with Intravitreal Foscarnet

Case Report: Herpes Simplex Virus Type 2 Acute Retinal Necrosis With Viral Encephalitis in Children

Background

Few cases concerning acute retinal necrosis with viral encephalitis in children have been reported, especially cases where the fundus cannot be identified due to severe vitreous opacity in the early stage that makes diagnosis difficult.

Methods

We conducted a retrospective review of an unusual case of herpes simplex virus-2 (HSV-2) acute retinal necrosis with viral encephalitis in an immunocompetent child, along with a review of relevant literature published up to September 2021.

Result

An 11-year-old girl presented with an approximate 20-day history of ocular redness and decreased visual acuity in the left eye. Examination revealed anterior uveitis and vitreous opacity in the left eye. An anterior chamber tap was performed because the fundus could not be observed clearly, and the aqueous humor was positive for HSV-2 DNA. Cerebrospinal fluid also tested positive for HSV-2. She was diagnosed with acute retinal necrosis syndrome and viral encephalitis. The condition was controlled with timely antiviral and steroid therapy. She was also treated with prophylactic laser therapy to prevent retinal detachment during subsequent follow-up. The pathogenesis, diagnosis, and treatment of HSV-2 acute retinal necrosis in children and the association between acute retinal necrosis and viral encephalitis are further discussed, based on published literature.

Conclusion

HSV-2-related pediatric acute retinal necrosis may be due to the acquisition of subclinical infection with HSV-2 during parturition, followed by reactivation of the virus latent in the body on account of certain factors. Moreover, it may be complicated with viral encephalitis. For suspected cases with invisible fundus, early intraocular fluid examination is especially helpful for differential diagnosis. Early diagnosis, early treatment, and timely prophylactic laser treatment to prevent retinal detachment are key to a better prognosis. Physicians need to pay attention to such suspected cases during diagnosis and treatment.

Ultra-wide-field fundus imaging of acute retinal necrosis: clinical characteristics and visual significance

OBJECTIVES

To investigate the clinical characteristics of acute retinal necrosis (ARN) with ultra-wide-field imaging (UWFI) and analyse their visual significance.

METHODS

Clinical and UWFI records of patients diagnosed with ARN at a single centre over 2 years were reviewed.

RESULTS

In 38 eyes of 35 patients, the clinical manifestations of ARN on UWFI included patchy (12 eyes) or fan-shaped necrotic lesions (26 eyes), retinal arterial obliteration (38 eyes), vitritis (38 eyes), retinal venous haemorrhage (19 eyes), and vitreous haemorrhage (6 eyes). Retinal detachment was associated with the number of retinal quadrants involved (β = 2.145, P = 0.005). LogMAR BCVA at last follow-up was associated with logMAR BCVA at presentation (β = 0.473, P = 0.004) and retinal detachment (β = 0.367, P = 0.020).

CONCLUSION

UWFI is useful for detecting retinal lesions in ARN, especially peripheral lesions or through opaque media, and provides valuable information concerning visual prognosis.

Emerging concepts in the management of acute retinal necrosis

Acute retinal necrosis (ARN), also known as Kirisawa-type uveitis, is an uncommon condition caused by infection of the retina by one of the herpes family of viruses, most typically varicella zoster virus or herpes simplex virus and less commonly cytomegalovirus. Clinical diagnosis can be challenging and is often aided by PCR-based analysis of ocular fluids. Treatment typically involves extended use of one or more antiviral agents. Long term retinal detachment risk is high. We review the literature on ARN and present an approach to the diagnosis and management of this serious condition.

Concomitant Intravitreal Ganciclovir and Dexamethasone Therapy in the Management of Acute Retinal Necrosis in a Patient Previously Treated with Oral Famciclovir

Several treatments have been reported for acute retinal necrosis (ARN). We report a case of treatment with intravitreal injection of ganciclovir and dexamethasone in addition to oral valacyclovir in a patient who was previously treated with oral famciclovir for ipsilateral herpes zoster ophthalmicus (HZO).

Acute retinal necrosis (ARN) in the context of neonatal HSV-2 exposure and subconjunctival dexamethasone: case report and literature review

HSV-2 is an important cause of the acute retinal necrosis (ARN) syndrome in younger patients. We describe an atypical case of HSV-2 ARN in the context of neonatal exposure and subconjunctival steroid injection. Clinicians should be aware of the association of neonatal or congenital exposure to HSV-2 as a risk factor for this disease because early treatment may improve outcome and/or avoid involvement of both eyes.

Acute retinal necrosis caused by herpes simplex virus type 2 in children: reactivation of an undiagnosed latent neonatal herpes infection

Herpes simplex virus type 2 (HSV-2) is known to cause acute retinal necrosis (ARN). The availability of HSV-2-specific polymerase chain reaction tests for diagnostic analysis has greatly increased our ability to discriminate ARN caused by HSV-2 from ARN caused by either herpes simplex virus type 1 or varicella zoster virus (VZV). Of great interest, HSV-2 appears to be the most common cause of viral ARN in children and adolescents. Although a few children with ARN are known to have had neonatally acquired herpes infection, most children lack a history of known herpes disease. Thus, the origin of the HSV-2 infection is a mystery. The hypothesis of this review is that HSV-2 ARN in children and adolescents may be the first sign of a previously undiagnosed and asymptomatic neonatal HSV-2 infection, which has reactivated several years later from latency in a cranial nerve and entered the retina. The review brings together 7 previously published ARN cases, plus one new case is added. Thus, this review also expands the spectrum of complications from neonatal HSV-2 infection.

Acute retinal necrosis caused by herpes simplex virus type 2 in a 3-year-old Japanese boy

Acute retinal necrosis (ARN), which is characterized by rapidly progressing peripheral retinal necrosis, is caused mainly by herpes simplex virus type 1, herpes simplex virus type 2 (HSV-2), or varicella-zoster virus. A previously healthy 3-year-old Japanese boy developed ARN in his left eye after being bruised by a milk container. HSV-2 DNA was detected in the aqueous humor of the affected eye. Serological testing suggested that the route of infection was from mother to child, although there was no past history of apparent HSV-2 infection. Childhood ARN has not been previously reported in Japan, possibly because of the low seroprevalence of HSV-2 in Japanese women. Pediatricians must be aware of this rare disease, which can affect individuals without a previous history of HSV even in a country with a low seroprevalence of HSV-2.

Incidence of endophthalmitis related to intravitreal injection of bevacizumab and ranibizumab

PURPOSE

To report the overall incidence of endophthalmitis associated with office based intravitreal injections of bevacizumab and ranibizumab.

METHODS

This is a retrospective, consecutive, multicenter case series involving four large clinical sites. Included were all patients receiving at least one injection of intravitreal bevacizumab or intravitreal ranibizumab. Follow-up after each injection was at least 4 weeks.

RESULTS

A total of 12,585 injections of intravitreal bevacizumab and 14,320 injections of intravitreal ranibizumab were given during the study period. Infectious endophthalmitis developed in three patients after administration of bevacizumab and in three patients after administration of ranibizumab. Four of these patients were culture positive. Rates of endophthalmitis were 0.02% and 0.02%, respectively, with an overall rate of 0.02%.

CONCLUSION

The rate of endophthalmitis associated with intravitreal bevacizumab and ranibizumab is low, with an incidence of approximately 1 in 4,500 injections.