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Ngathaweesuk Y, Hendrikse J, Groot-Mijnes JDFD, de Boer JH, Hettinga YM. Causes of infectious pediatric uveitis: A review. Surv Ophthalmol 2024; 69:483-494. [PMID: 38182040 DOI: 10.1016/j.survophthal.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/11/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024]
Abstract
Infectious pediatric uveitis is a rare disease that can cause severe ocular damage if not detected rapidly and treated properly. Additionally, early identification of an infection can protect the child from life-threatening systemic infection. Infectious uveitis can be congenital or acquired and may manifest as a primary ocular infection or as a reactivation. Nevertheless, publications on infectious paediatric uveitis are usually limited to a small number of patients or a case report. So far, most studies on uveitis in children have focused primarily on noninfectious uveitis, and a systematic study on infectious uveitis is lacking. In this review, we summarize the literature on infectious uveitis in pediatric populations and report on the epidemiology, pathophysiology, clinical signs, diagnostic tests, and treatment. We will describe the different possible pathogens causing uveitis in childhood by microbiological group (i.e. parasites, viruses, bacteria, and fungi). We aim to contribute to early diagnosis and management of infectious pediatric uveitis, which in turn might improve not only visual outcome, but also the general health outcome.
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Affiliation(s)
- Yaninsiri Ngathaweesuk
- Department of Ophthalmology, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Jytte Hendrikse
- Department of Ophthalmology, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - Jolanda Dorothea Francisca de Groot-Mijnes
- Department of Ophthalmology, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Joke Helena de Boer
- Department of Ophthalmology, University Medical Centre Utrecht, Utrecht, the Netherlands
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He L, Duan J, Shang Q. Case Report: Herpes Simplex Virus Type 2 Acute Retinal Necrosis With Viral Encephalitis in Children. Front Med (Lausanne) 2022; 9:815546. [PMID: 35372449 PMCID: PMC8967414 DOI: 10.3389/fmed.2022.815546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/14/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Luyao He
- Department of Ophthalmology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jialiang Duan
- Department of Ophthalmology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qingli Shang
- Department of Ophthalmology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Suzuki K, Namba K, Hase K, Mizuuchi K, Iwata D, Ito T, Kitaichi N, Takase H, Ishida S. A case of Epstein-Barr virus acute retinal necrosis successfully treated with foscarnet. Am J Ophthalmol Case Rep 2022; 25:101363. [PMID: 35146210 PMCID: PMC8818534 DOI: 10.1016/j.ajoc.2022.101363] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 12/27/2021] [Accepted: 01/22/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Epstein-Barr virus (EBV) is a herpes virus known to cause infectious mononucleosis and several other human disorders. Ocular EBV infections that have been reported include uveitis, retinal vasculitis, and acute retinal necrosis (ARN). ARN is usually caused by herpes simplex virus (HSV) or varicella-zoster virus (VZV). ARN that is caused by EBV (EBV-ARN) is rarely seen, and only a few cases have been reported. The visual prognosis for EBV-ARN is poor, and no treatment strategy has been established. We report on a patient who was treated successfully for EBV-ARN. Observation An 80-year-old female who had been treated with prednisolone at 5 mg/day and methotrexate at 2 mg/week for rheumatoid arthritis visited our hospital because of blurred vision in her left eye. Her left visual acuity was 20/50, and extensive white-yellowish retinal lesions at the temporal periphery with retinal hemorrhages were seen through vitreous haze. The DNA sequence of EBV, but not of HSV, VZV, or cytomegalovirus, was detected by a polymerase chain reaction (PCR) assay in the aqueous humor (4.2 × 106 copies/ml), with EBV also being positive in serum (3.5 × 102 copies/ml). The patient received 2 mg of intravitreal ganciclovir injections twice with a 3-day interval and intravenous infusion of acyclovir at 750 mg/day for 7 days; however, the retinal white lesions expanded rapidly, then dose of prednisolone was increased (40 mg/day) and vitrectomy was performed 10 days after the initial visit. After the surgery, the retinal lesion continued to enlarge. Vitreous samples showed high copies of EBV (1.2 × 108 copies/ml). Following treatment with intravenous foscarnet (4800 mg/day), which replaced the acyclovir application, the retinal white lesions gradually diminished, leaving retinal scars. To date, the patient has developed no retinal detachment and shows visual acuity over 6/60 in the left eye along with silicone oil. Conclusions We experienced a case of EBV-ARN that was refractory to systemic acyclovir and topical ganciclovir but responded effectively to systemic foscarnet after vitrectomy. Although the clinical management remains challenging in this disease, foscarnet is considered to be one of the candidate drugs for EBV infections.
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Affiliation(s)
- Kayo Suzuki
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kenichi Namba
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Corresponding author. Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Keitaro Hase
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazuomi Mizuuchi
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Daiju Iwata
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takako Ito
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Nobuyoshi Kitaichi
- Department of Ophthalmology, Health Sciences University of Hokkaido, Sapporo, Japan
| | - Hiroshi Takase
- Department of Ophthalmology & Visual Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Susumu Ishida
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Silpa-Archa S, Sriyuttagrai W, Foster CS. Treatment for Epstein-Barr Virus-associated uveitis confirmed by polymerase chain reaction: Efficacy of Anti-Viral Agents and a literature review. J Clin Virol 2022; 147:105079. [PMID: 35007895 DOI: 10.1016/j.jcv.2022.105079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND There are still many research challenges and unanswered questions in relation to Epstein-Barr virus-associated uveitis. These include the presence of Epstein-Barr virus (EBV) DNA in asymptomatic patients, its pathogenicity in the uveitis eye, and the role of antiviral therapy for EBV-associated intraocular inflammation. METHODS This was a retrospective review of prospectively collected data from the Ophthalmology Department, Rajavithi Hospital between 2015 and 2020. A qualitative assay using multiplex real-time PCR was performed to detect pathogen genes from specimens obtained from a total of 344 patients. The main outcome measure was treatment success defined by clinical improvement and absence of viral DNA confirmed by PCR. RESULTS Of the 35 cases, 24 with complete data were enrolled in the study, including 22 with post-treatment PCR results. Sixty-seven percent were HIV-infected, and other plausible causes or coinfection with other pathogens were found in 75% of patients. Cytomegalovirus (38%) was the most common co-infecting pathogen. The most commonly employed regimen was a combination of systemic acyclovir and intravitreal ganciclovir injection (58%). Of the 22 cases who had post-treatment PCR results, absence of detection of the virus by PCR in the intraocular fluid after treatment was demonstrated in 73% of patients. CONCLUSION Patients with EBV infection can be simultaneously co-infected with other pathogens. Systemic acyclovir and ganciclovir achieved clinical improvement in most cases, and EBV infection was cured in the majority of patients.
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Affiliation(s)
- Sukhum Silpa-Archa
- Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, 10400 Thailand.
| | - Wararee Sriyuttagrai
- Department of Ophthalmology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, 10400 Thailand
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA; Ocular Immunology & Uveitis Foundation, Waltham, MA, USA; Harvard Medical School, Boston, MA, USA
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Chan EW, Sun V, Eldeeb M, Kapusta MA. EPSTEIN-BARR VIRUS ACUTE RETINAL NECROSIS IN AN IMMUNOCOMPETENT HOST. Retin Cases Brief Rep 2021; 15:412-416. [PMID: 30358736 DOI: 10.1097/icb.0000000000000819] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE To describe a case of Epstein-Barr virus (EBV)-associated acute retinal necrosis (ARN) in an immunocompetent patient and to summarize the clinical features of published molecularly confirmed EBV-ARN cases. METHODS Case report and literature review. RESULTS An 83-year-old immunocompetent woman with unilateral ARN presented with visual acuity of light perception. Oral valacyclovir was started. One week later, vitrectomy was conducted for worsening inflammation. Intraoperatively, a severe confluent necrotizing retinitis and occlusive vasculitis involving all four quadrants of posterior and peripheral retina were noted. Vitreous polymerase chain reaction was exclusively positive for EBV. Other autoimmune, infective, and hematological work-up was negative. The retinitis resolved 3 months later, but with significant macular and generalized retinal atrophy, visual acuity remained light perception. From the literature, there are four EBV-ARN cases (six eyes) diagnosed based on polymerase chain reaction or fluorescence in-situ hybridization of vitreous or retinal samples. All patients were immunocompromised or on immunosuppressive treatment. Presenting visual acuity was light perception or worse in 3/6 eyes. Three patients received systemic acyclovir-based therapy. Vitrectomy was performed in 4/6 eyes between 4 and 8 weeks from disease onset. All cases had involvement of the posterior and peripheral retina. Retinal detachment occurred in 2/6 eyes, and final visual acuity was no light perception in 3/6 eyes. CONCLUSION This case expands the clinical spectrum of EBV-ARN to include infection in immunocompetent hosts. Epstein-Barr virus-ARN seems to be characterized by a global peripheral and posterior fulminant retinitis, with adverse visual acuity outcomes despite systemic acyclovir-based therapy. The benefits of adjunctive intravitreal foscarnet, systemic steroids, and early vitrectomy may warrant further investigation.
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Affiliation(s)
- Errol W Chan
- Department of Ophthalmology, Jewish General Hospital, Montreal, Quebec, Canada
- Montreal Retina Institute, Montreal, Quebec, Canada ; and
- McGill Academic Eye Centre, McGill University, Montreal, Quebec, Canada
| | - Vincent Sun
- Department of Ophthalmology, Jewish General Hospital, Montreal, Quebec, Canada
- McGill Academic Eye Centre, McGill University, Montreal, Quebec, Canada
| | - Mohab Eldeeb
- Montreal Retina Institute, Montreal, Quebec, Canada ; and
| | - Michael A Kapusta
- Department of Ophthalmology, Jewish General Hospital, Montreal, Quebec, Canada
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Victor AA, Sukmana N. RETINAL VASCULITIS ASSOCIATED WITH EPSTEIN-BARR VIRUS INFECTION, A CASE REPORT. Retin Cases Brief Rep 2018; 12:314-317. [PMID: 28030457 DOI: 10.1097/icb.0000000000000508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE To report a case of retinal vasculitis associated with Epstein-Barr virus infection. METHODS Case report. RESULTS A 26-year-old woman came with blurry vision. Funduscopy illustrated vasculitis with frosted branch-like appearance. The patient was treated with systemic acyclovir and topical steroid. Circulating polymerase chain reaction was positive for Epstein-Barr virus antibodies. Two months of treatment resolved the clinical manifestations. CONCLUSION Epstein-Barr infection should be considered as the etiology of retinal vasculitis with similar clinical manifestations.
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Affiliation(s)
- Andi A Victor
- Vitreo-Retinal Division, Department of Ophthalmology, Faculty of Medicine, University of Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
- Prof. Dr. Isak Salim Aini Eye Hospital, Jakarta, Indonesia
| | - Nanang Sukmana
- Division of Clinical Allergy and Immunology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
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Yu J, Ashworth J, Hughes S, Jones N. Varicella-zoster virus necrotising retinitis, retinal vasculitis and panuveitis following uncomplicated chickenpox in an immunocompetent child. BMJ Case Rep 2018; 2018:bcr-2017-223823. [PMID: 29622711 DOI: 10.1136/bcr-2017-223823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 4-year-old girl presented with acute left visual loss 4 weeks after uneventful chickenpox. She was found to have left necrotising retinitis and profound retinal vasculitis and vitritis. Aqueous humour was PCR positive for varicella-zoster virus. Combined intravenous and intravitreal antiviral treatment led to rapid improvement with settled retinitis, no vascular occlusion and good recovery of vision. Her recent coinfection with Epstein-Barr virus may have acted to provoke the retinitis.
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Affiliation(s)
- Jonathan Yu
- Manchester Royal Eye Hospital, Manchester, UK
| | - Jane Ashworth
- Department of Ophthalmology, Manchester Royal Eye Hospital, Manchester, UK
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Stefanou C, Tzortzi C, Georgiou F, Timiliotou C. Combining an antiviral with rituximab in EBV-related haemophagocytic lymphohistiocytosis led to rapid viral clearance; and a comprehensive review. BMJ Case Rep 2016; 2016:bcr-2016-216488. [PMID: 27941111 DOI: 10.1136/bcr-2016-216488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Epstein-Barr virus (EBV)-related haemophagocytic lymphohistiocytosis (EBVr-HLH) has a better prognosis when the virus is rapidly cleared, but the best antiviral approach is controversial. We present a patient to whom the therapeutic standard rituximab was co-administered with valacyclovir and an HLH-specific treatment with favourable viral and clinical responses. We conducted an extensive literature review and contacted several world reference centres and experts to inquire about their approaches and experience. We conclude that antivirals are infrequently used for EBVr-HLH, despite their laboratory-proven and likely clinical beneficial effect on some EBV-related diseases. However, the role of antivirals remains obscure. Concerns about their lack of efficacy are based on observational data and reports of the cellular tropism of EBV. Therefore, the adjunct use of antivirals may be considered when myelotoxicity is not the primary concern, and related outcomes should be systematically recorded to produce higher quality evidence.
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Roquelaure D, Harbarth S, Schutz JS, Thumann G, Chronopoulos A. Epstein-Barr-Virus-assoziierte akute retinale Nekrose. Ophthalmologe 2016; 113:864-866. [DOI: 10.1007/s00347-016-0229-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Keorochana N. A case report of Epstein-Barr virus-associated retinal vasculitis: successful treatment using only acyclovir therapy. Int Med Case Rep J 2016; 9:213-8. [PMID: 27524923 PMCID: PMC4966646 DOI: 10.2147/imcrj.s107089] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to describe a presumed case of Epstein–Barr virus (EBV)-associated retinal vasculitis in a 42-year-old female with sudden unilateral vision loss and successful treatment with acyclovir therapy. Diagnostic vitreous biopsy of the right eye was performed to test for EBV and other known infectious causes of retinitis and evaluate vitreous cells and serological testing. Vitreous polymerase chain reaction viral DNA testing result was positive for EBV but negative for herpes simplex virus, varicella-zoster virus, and cytomegalovirus. Serologic testing was negative for toxoplasma gondii, syphilis, tuberculosis, and HIV. Histopathologic analysis of vitreous cells revealed atypical lymphocytes. Fluorescein angiography showed disk leakage, occluded retinal artery, peripheral vascular leakage, and ischemic area of the right eye. Intravenous acyclovir, 10 mg/kg/d, was prescribed for 14 days followed by oral acyclovir for 3 months. All lesions have become quiet. EBV may be a cause of retinal disease, and intravenous acyclovir is a successful treatment choice.
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Affiliation(s)
- Narumon Keorochana
- Department of Ophthalmology, Phramongkutklao Hospital, Bangkok, Thailand
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Papageorgiou E, Ch'ng S, Kulkarni A, Anwar S, Empeslidis T. Fourth cranial nerve palsy and bilateral acute retinal necrosis following human herpesvirus 6 infection of the central nervous system. Ocul Immunol Inflamm 2013; 22:228-32. [PMID: 24328436 DOI: 10.3109/09273948.2013.856533] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Acute retinal necrosis (ARN) is a rare, potentially blinding condition typically affecting immunocompetent individuals. It is defined by the clinical triad of vitreous inflammation, occlusive vasculopathy, and progressive retinal necrosis, usually located in peripheral retina with circumferential extension. Varicella zoster virus (VZV), herpes simplex virus (HSV), Epstein-Barr virus (EBV) and occasionally cytomegalovirus (CMV) are the common causative agents of ARN. Reports of human herpesvirus 6 (HHV6) infection of the central nervous system (CNS) associated with ocular inflammatory disease are extremely rare. We here report the case of a 22-year-old immunocompetent male who presented with acute bilateral ARN and fourth nerve palsy, following HHV6 infection of the CNS and EBV infectious mononucleosis.
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Affiliation(s)
- Eleni Papageorgiou
- Department of Ophthalmology, Leicester Royal Infirmary, University of Leicester , Leicester , UK
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Fraser SG. Editorial foreword. Clin Ophthalmol 2008; 2:i-ii. [PMID: 19668711 PMCID: PMC2693983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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