Herpes simplex keratitis in renal transplant patients

Herpetic Keratitis Following Treatment of Acute Antibody-Mediated Rejection in a Renal Transplantation Recipient

We report an incident case of herpetic keratitis in a renal transplant recipient treated for acute renal allograft rejection. A lady in her forties, a renal transplant recipient on treatment for allograft rejection, was referred with mild ocular symptoms in the right eye for two days. On evaluation, she had mild conjunctival hyperemia and extensive herpetic epithelial keratitis involving the limbal and central corneas. The patient healed without sequelae from the antivirals and lubricants. Viral keratitis in immunosuppressed patients should be suspected, even in patients with mild symptoms, as early initiation of treatment can prevent rapid stromal involvement and scarring.

Insights From the Eye for Patients With Kidney Transplant

The eye and the kidney share structural and developmental similarities on a cellular and clinical level, and they are often affected by the same disease processes. Performing an eye exam to look for signs of conditions such as hypertension and diabetes can provide a helpful window into the health of the kidney. Patients with kidney transplants (KT) are a unique population that require close monitoring. These patients are maintained on a number of immunosuppressive medications and may face complications such as medication side effects, infections, and graft rejection. Patients with KT are at higher risk of both infectious and noninfectious eye conditions related to underlying systemic disease or use of immunosuppressive medications. Screening for eye conditions is important because preserving visual function is integral to quality of life, and also because the eye exam can help with early detection and treatment of systemic conditions. Here we describe some of the common eye findings and conditions in patients with KT. We recommend that patients with KT receive annual eye exams, and we hope that the information provided here can help nephrologists become more familiar with eye findings and identify situations where a referral to ophthalmology is warranted.

Virus-Induced Anterior Uveitis (VIAU) in Immunocompromised Patients

PURPOSE

To describe the clinical characteristics, diagnosis, and treatment of VIAU in immunocompromised patients.

METHODS

A critical review of literature was performed.

RESULTS

Diagnosis and treatment of VIAU in immunocompromised patients may be a challenge due to atypical clinical-courses, severe presentations, and more frequent recurrences. A conclusive diagnosis can be made by aqueous-humour PCR-analysis. Visual prognosis depends on early diagnosis and prompt treatment. Frequent ocular examinations are recommended in HIV patients with CD-4-counts below 100 in order to rule out opportunistic ocular coinfections. It is essential to bear in mind the potential side-effects of therapeutic interventions and consider the possibility of Immune Recovery Uveitis (IRU) in eyes with treated viral retinitis after the initiation of HAART.

CONCLUSIONS

Early diagnosis and treatment of VIAU in immunocompromised patients can be achieved with high suspicion, recognizing clinical features, and obtaining specimens for molecular diagnostic testing in order to avoid usually severe ocular morbidity.

Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis

BACKGROUND

Eye disease due to herpes simplex virus (HSV) commonly presents as epithelial keratitis which, though usually self-limiting, may persist or progress without treatment.

OBJECTIVES

To compare the relative effectiveness of antiviral agents, interferon, and corneal debridement in the treatment of HSV epithelial keratitis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 12), PubMed (January 1946 to 31 December 2014), EMBASE (January 1980 to 31 December 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to 31 December 2014), System for Information on Grey Literature in Europe (OpenGrey) (January 1995 to 31 December 2014), BIOSIS (January 1926 to 5 May 2014), Scopus (January 1966 to 31 December 2014), Japan Science and Technology Institute (J-Global) (January 1975 to 31 December 2014), China National Knowledge Infrastructure (CNKI) (January 1979 to 31 December 2014), British Library's Electronic Table of Contents (Zetoc) (January 1993 to 7 May 2014). We looked for trials listed on the the metaRegister of Controlled Trials (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en), Chinese Clinical Trial Registry, the U.S. Food and Drug Administration (FDA) (www.fda.gov/), National Institute for Health and Clinical Excellence (NICE) (www.

EVIDENCE

nhs.uk) and the European Medicines Agency (EMA) (www.ema.europa.eu/ema/) as of 31 December 2014. There were no language or date restrictions in the search for trials. We also culled literature digests and conference proceedings as of 15 April 2014. There were no language or date restrictions in the search for trials.

SELECTION CRITERIA

Randomised and quasi-randomised trials of HSV dendritic or geographic epithelial keratitis were included that reported the proportion of eyes healed at one week, two weeks, or both after enrolment.

DATA COLLECTION AND ANALYSIS

We tabulated data on study characteristics, risk of bias, and outcomes and used direct comparisons to estimate a risk ratio (RR) and, when feasible, a hazard ratio (HR) with a 95% confidence interval (CI). Heterogeneity was assessed by an inconsistency index. A multiple treatment comparison meta-analysis consolidated direct and indirect comparisons of relative healing at 14 days.

MAIN RESULTS

One hundred thirty-seven studies involving 8333 eyes met the inclusion criteria. Placebo-controlled studies were heterogeneous in comparison with idoxuridine (RR 1.74; 95% CI 1.03 to 2.91) and few in number for vidarabine (RR 1.81; 95% CI 1.09 to 3.01), interferon (RR 1.32; 95% CI 1.06 to 1.64), and debridement. Vidarabine (RR 1.13; 95% CI 1.02 to 1.25), trifluridine (RR 1.30; 95% CI 1.18 to 1.43), acyclovir (RR 1.23; 95% CI 1.14 to 1.34), and brivudine (RR 1.34; 95% CI 1.18 to 1.51) were more effective than idoxuridine. Trifluridine (RR 1.17; 95% CI 1.03 to 1.32) and acyclovir (RR 1.11; 95% CI 1.03 to 1.19) were more effective than vidarabine. No significant differences in healing emerged among trifluridine, acyclovir, brivudine, and foscarnet although few studies compared brivudine or foscarnet with other antivirals. Any potential advantage of ganciclovir compared to acyclovir was mitigated by study heterogeneity and possible publication bias. Only one study evaluated the joint use of two topical antivirals. In a limited number of studies, oral acyclovir (RR 0.92; 95% CI 0.79 to 1.07) or the combination of oral acyclovir with a topical antiviral (RR 1.36; 95% CI 0.68 to 2.74) appeared as effective as a single topical antiviral agent. Compared to topical antiviral monotherapy, the combination of an antiviral with either interferon or debridement had inconsistent effects on expediting healing and improving outcome.

AUTHORS' CONCLUSIONS

Placebo-controlled studies of HSV epithelial keratitis are limited to superseded interventions. Trifluridine and acyclovir are more effective than idoxuridine or vidarabine and similar in therapeutic effectiveness. Brivudine and foscarnet do not substantially differ in effectiveness from trifluridine or acyclovir. Ganciclovir is at least as effective as acyclovir. The addition of interferon to a nucleoside antiviral agent and the combination of debridement with antiviral treatment need to be further assessed to substantiate any possible advantage in healing.

Herpes Simplex Keratitis in Rheumatoid Arthritis Patients

PURPOSE

To describe a series of 5 patients with herpes simplex virus keratitis (HSK) and rheumatoid arthritis (RA) under immunosuppressive treatment.

METHODS

Retrospective study. Detailed data were obtained regarding symptoms and signs at the initial evaluation, treatment, microbiological diagnostic tests, evolution, and outcomes.

RESULTS

Five patients with HSK and RA were identified. Bilateral involvement occurred in 2 patients (40%). Epithelial keratitis was diagnosed in 5 eyes. Three eyes showed severe melting with eye perforation. Gram-positive bacterial co-infections were common in the group with stromal keratitis. We did not find differences in the evolution of the disease based on anti-rheumatoid treatment.

CONCLUSIONS

The characteristics of HSK in patients with RA differed from HSK in immunocompetent patients. The stromal keratitis cases were very aggressive and difficult to manage, with perforation and gram-positive bacterial co-infection as frequently associated conditions. Prophylactic therapy at standard doses was unsuccessful to avoid recurrences.

[Severe infectious keratitis in renal transplant patient: a case report]

Keratitis occurring in renal transplant patients are often severe, with difficult management. We describe the case of a renal transplant patient, 44 year-old man, with history of recurrent herpetic keratitis, which developed an impending corneal perforation. Conjunctival smear showed the presence of amoebic cysts. Anti-amoebic treatment was undertaken in addition with oral aciclovir, and a therapeutic penetrating keratoplasty was performed. An ulceration of the graft occurred within five months. Ocular samples showed the presence of Candida albicans. Despite aggressive antifungal therapy, he required a second therapeutic penetrating keratoplasty for graft perforation. One month later, we noted a recurrence of the ulcer with corneal thinning which evolved to perforation.

Intravenous acyclovir treatment for extensive herpetic keratitis in a liver transplant patient

Herpetic infection is a common complication among immune suppressed patients following heart, kidney and bone marrow transplantations, in leukemia patients, in AIDS patients, and during treatment with cytotoxic drugs. In the cases described in the literature, oral acyclovir was recommended as a treatment for the acute infection, as well as for prophylaxis. Intravenous acyclovir is not a routine treatment for herpetic keratitis, but is recommended for cases of insufficient clinical response to oral treatment, and defective absorption of acyclovir by the gastrointestinal tract. We present a patient who underwent 4 liver transplantations, was treated regularly with immunosuppressive drugs, and who developed extensive herpetic keratitis. The keratitis was resistant to both topical ointment and oral acyclovir treatment. Recovery was only achieved following the intravenous administration of acyclovir. We recommend intravenous acyclovir treatment at a very early stage for immune suppressed patients with extensive herpes simplex keratitis.