Fulminant bilateral acute retinal necrosis complicated with secondary herpes simplex type-1 viral encephalitis: A case report

Acute retinal necrosis: pathophysiological aspects, diagnosis, and treatment

Acute retinal necrosis (ARN) is a devastating viral infection commonly associated with varicella zoster virus (VZV) and herpes simplex virus types 1 and 2 (HSV-1, HSV-2). Typically, ARN affects individuals without immune status disorders between the ages of 50-70. In two-thirds of the cases, one-eye involvement is observed and the inflammation can be presented as panuveitis. The most characteristic clinical manifestations are vitreitis, occlusion of the retinal arterioles, and peripheral necrotizing retinitis. Retinitis presents with the appearance of deep, multifocal, yellowish-white foci, typically localized in the peripheral retina. Systemic antivirals are the first treatment of choice for ARN. The goal of the therapy is to stop the viral replication and disease progression in the affected eye, as well as to prevent involvement of the healthy eye. The other eye can be attacked in an interval of 5 days to 30 years. The visual prognosis after illness is poor. Early diagnosis and timely initiation of treatment play an important role in maintaining visual acuity and preventing the other eye from being affected.

Clinical Spectrum of Uveitis Induced by Herpes Simplex Virus with Posterior Pole Involvement at Initial Presentation: A Case Series and Literature Review

PURPOSE

To report four cases of herpes simplex virus-induced uveitis with posterior pole involvement at initial presentation.

CASE PRESENTATIONS

In case 1, the posterior pole initially showed dense vitreous hemorrhage from the optic disc, multiple subretinal lesions around the optic disc, and retinal arterial sheath prior to retinal necrosis. In case 2, the posterior pole presented with optic disc edema, retinal venous tortuosity, and arterial sheathing around the optic disc prior to the peripheral retinal necrosis. In case 3 diagnosed with posterior herpetic uveitis, the posterior pole showed retinal arterial sheath and macular structural abnormities. In case 4, the posterior pole demonstrated optic disc swelling, along with perivascular retinal hemorrhage 4 days prior to peripheral retinal necrosis.

CONCLUSIONS

Posterior pole involvement might occur either solely or before the development of peripheral retinal necrosis in patients with herpes simplex virus-induced acute retinal necrosis with and without prior central nervous system herpetic virus infection.

A Review of the Treatment of Herpes Simplex Virus-1 Encephalitis in Six Immunocompetent Patients

Introduction

The optimal treatment regimen for herpes simplex-1 (HSV-1) encephalitis is ill-defined. Current guidelines recommend the initiation of acyclovir in all suspected cases of encephalitis; however, there is limited research regarding the details of acyclovir treatment or the adjuvant use of corticosteroids. Specifically, there is a paucity of evidence-based guidelines detailing the optimal management of HSV-1 encephalitis in immunocompetent patients. In this study, we conducted a review of cases of immunocompetent patients with HSV-1 encephalitis to compare patterns in treatment and outcomes. 

Methods

A review of the literature was performed using PubMed using the terms herpes encephalitis, HSV, herpes zoster, and immunocompetent to identify cases of HSV-1 encephalitis in immunocompetent patients. The results were screened for cases describing the treatment regimen of HSV-1 encephalitis-positive, immunocompetent patients. 

Results

Six cases were identified. All six patients were treated with acyclovir with one patient receiving adjuvant corticosteroid therapy. Additionally, three patients were found to have acyclovir resistance and were transitioned to foscarnet. Eventually, one patient expired, two patients recovered with chronic morbidities of varying severity, and three patients made a full recovery. 

Discussion

Inconsistencies in the patient's disease course, therapeutic regimen, and comorbidities could all play a role in the varying case outcomes. While the optimal timing and composition of therapies in HSV-1 encephalitis in immunocompetent patients are still unclear, it seems the timely administration of antiviral treatment remains essential. Further research is needed to optimize HSV-1 encephalitis therapeutic regimens and improve patient outcomes. 

Uveo-meningeal syndrome secondary to Herpes Simplex Virus related acute retinal necrosis

Purpose

To present a rare case of uveo-meningeal syndrome secondary to herpes simplex virus (HSV-1) in a patient with acute retinal necrosis.

Observations

A 49-year-old female with a past medical history of herpes simplex encephalitis 18 years prior presented with a 3-day history of right sided headache and decreased vision of the right eye. Her visual acuity was 20/30 in the right eye and 20/20 in the left eye. Clinical examination revealed right relative afferent pupillary defect, panuveitis, and retinal necrosis. Examination of the left eye was unremarkable. Cerebral spinal fluid (CSF) analysis by polymerase chain reaction (PCR) was negative for herpes simplex virus 1 (HSV-1) but did reveal pleocytosis consistent with meningitis. The patient was admitted and empirically treated with intravenous acyclovir (10 mg/kg every 8 hours) and systemic steroids. Topical steroids and cycloplegia were also started. Magnetic resonance imaging revealed no leptomeningeal, pachymeningeal, or parenchymal enhancement. Systemic autoimmune and infectious workup were unremarkable. Based on clinical exam findings and negative PCR results, an anterior chamber tap was performed with aqueous fluid PCR testing which revealed 71,000 copies of HSV-1. A repeat lumbar puncture was performed on day three of admission and revealed a decrease in pleocytosis after initiation of acyclovir therapy and remained negative for HSV on PCR testing. She was discharged home on intravenous acyclovir, topical steroids, and topical cycloplegics. Her retinal necrotic lesions continued to regress and her headaches continued to improve.

Conclusions and importance

Uveo-meningeal syndromes are a rare clinical entity that involve the uvea, retina, and meninges. This case highlights the importance of aqueous fluid PCR testing despite negative CSF PCR, as it may hasten treatment with antiviral therapies to preserve vision and limit neurologic sequelae.

Bilateral acute retinal necrosis in premature newborn with skin, eye, and mouth infection presenting with vitreous and subretinal hemorrhage

A premature newborn with systemic sepsis due to Candida albicans and parapsilosis developed skin, eye, and mouth herpetic infection. Ocular disease presented atypically with vitritis and pre and subretinal hemorrhage due to herpes simplex virus-1 confirmed fulminant bilateral acute retinal necrosis. Pars plana vitrectomy revealed necrotizing retinitis with poor visual prognosis. The baby has survived suffering from multiple morbidities which include post-hemorrhagic hydrocephalus, chronic lung disease, patent ductus arteriosus, and developmental delay.

Acute retinal necrosis by herpes simplex virus type 1: an unusual presentation of a primary infection

Herpes simplex virus (HSV) can affect the central nervous system causing meningitis, encephalitis and, rarely, acute retinal necrosis. We present a case of a 46-year-old man, previously healthy complaining of a 5-day persistent headache and sudden loss of vision of his left eye that progressed to the right. We started ceftriaxone, methylprednisolone and acyclovir for suspected encephalitis with vasculitis. HSV-1 was identified in vitreous and aqueous humour. Therapy with acyclovir was maintained and two intravitreous boluses of foscarnet were administered, without improvement. Usually being a benign infection, HSV can, in rare cases like this, have catastrophic effects in the optic tract.