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Case Reports Medical Education Research Forum 2019

5-2019 HSV Acute Retinal Necrosis – A Painful Threat to Vision Hind Hadid Henry Ford Health System

Yusuf Alalwan Henry Ford Health System

Firas Askar Henry Ford Health System

Kevin Leikert Henry Ford Health System

Alexander Kuley Henry Ford Health System

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Recommended Citation Hadid, Hind; Alalwan, Yusuf; Askar, Firas; Leikert, Kevin; Kuley, Alexander; and Brar, Indira, "HSV Acute Retinal Necrosis – A Painful Threat to Vision" (2019). Case Reports. 38. https://scholarlycommons.henryford.com/merf2019caserpt/38

This Poster is brought to you for free and open access by the Medical Education Research Forum 2019 at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Case Reports by an authorized administrator of Henry Ford Health System Scholarly Commons. For more information, please contact [email protected]. Authors Hind Hadid, Yusuf Alalwan, Firas Askar, Kevin Leikert, Alexander Kuley, and Indira Brar

This poster is available at Henry Ford Health System Scholarly Commons: https://scholarlycommons.henryford.com/ merf2019caserpt/38 HSV Acute Retinal Necrosis – A Painful Threat to Vision

HSV Acute Retinal Necrosis: A Painful Threat to Vision Hind Hadid(1), Yusuf Alalwan(2), Firas Askar(2), Kevin Leikert(3), Alexander Kuley(3), Indira Brar(1) (1)Department of Infectious Diseases, (2)Department of Internal Medicine, (3)Department of Ophthalmology Henry Ford Health System, Detroit, MI

INTRODUCTION CASE 2 Ocular Herpes Simplex (HSV) is a serious infection A 27 year-old, 30-week pregnant, female with variable clinical manifestations ranging from presented to the ophthalmology clinic with 3 days of isolated blepharitis and keratitis to vision-threatening right eye pain, and blurry vision. Ocular uveitis and acute retinal necrosis (ARN). The presence exam showed periorbital swelling, panuveitis, disc of keratitis is a valuable diagnostic sign, however, when edema (blue circle), phlebitis, and focal with absent, the differential is wide, encompassing macular hemorrhages. autoimmune and idiopathic etiologies. We report two She was started empirically on Acyclovir, and cases of patients who presented with acute painful vision received intravitreal Ganciclovir+Foscarnet injections. loss, who subsequently were diagnosed with HSV-2 Aqueous and vitreous fluid PCR were HSV-2 positive; panuveitis and ARN. other infectious and rheumatological etiologies were ruled out. Despite maximal therapy, her vision CASE 1 deteriorated to Count Fingers within 36 hours, and over Figure 3: Fundus photograph demonstrating optic disc edema with A 33 year-old healthy female with three prior blurred optic disc margins and vessel obscuration (blue circle), multiple days her ARN progressed to , intraretinal hemorrhages (blue arrows), pheblitis and vasculitis (yellow episodes of unilateral iritis without definitive etiology, requiring surgical management. Despite aggressive arrows), and areas of focal retinitis (green arrows). presented to her ophthalmologist with painful red eye measures, her visual acuity only marginally improved. and photophobia similar to her previous iritis flare-ups. DISCUSSION On initial exam, she had conjunctival injection  ARN is most often caused by VZV infection. and 2+ cells in the anterior chamber. A clinical diagnosis  HSV ARN is rare and typically manifest as of anterior uveitis was made, and topical steroid therapy reactivation of latent disease. was initiated. However, compared to her prior episodes,  Previously reported risk factors for HSV uveitis her symptoms progressed over the next 3 days and on include trauma, older age and immunosuppression. subsequent exam, she had evidence of vitritis and  Treatment involves steroids and acyclovir. Treatment retinitis. She was diagnosed with panuveitis and ARN, is indicated to prevent progression of disease and initially most suspicious for endogenous bacterial involvement of the fellow eye. endophthalmitis. However, a diagnostic vitreous fluid PCR REFERENCES Figure 1: Slit lamp photograph Figure 2: Wide field pseudocolor fundus revealed HSV-2 infection. Upon further questioning, she demonstrating a large subconjuntival photograph demonstrating large areas of reported recurrent painful ulcers in the inguinal region. hemorrhage (blue arrow), chemosis retinitis in the peripheral retina. 1. Tran TH, Stanescu D, Caspers-Velu L, Rozenberg F, Liesnard C, Gaudric A, Lehoang P, (yellow arrow), and corneal edema Bodaghi B. Clinical characteristics of acute HSV-2 retinal necrosis. Am J Ophthalmol. She was treated with Valacyclovir 2g QID with (green arrow). 2004 May;137(5):872-9. 2. Sanjeet K Shahi, Acute retinal necrosis results in low vision in a young patient with a subconjectiveal steroid injections and retained good history of herpes simplex encephalitis, Clin Exp Optom. Aug 2017, 100: 208-213 vision. CONCLUSION . HSV panuveitis and ARN are rare but can occur in young, . High index of suspicion is key to correct diagnosis. immunocompetent hosts. . In cases of clinical uncertainty, ocular fluid PCR has high . The sequela of misdiagnosing such aggressive and potentially sensitivity. treatable infection can be vision-threatening.