Uveitis is an inflammatory process of the uvea, the pigmented vascular middle layer of the eye. The prevalence of uveitis in the USA is estimated at 57–115 cases/100,000 person-years; it is associated with 10% of cases of blindness.1,2 The cause of uveitis is complex, and it is estimated that a microbial aetiology can be demonstrated in only 17% of cases.1,2 The main microorganisms involved are T. gondii (3.8%–17.7%) and the herpesvirus family (HSV-1 and 2, varicella-zoster and cytomegalovirus) (4.5%–18.6%).2
The main eye infections caused by herpesviruses are keratitis, neurotrophic keratopathy, endotheliitis, uveitis and retinitis.3 Most of them are caused by HSV-1, except for some cases of neonatal infection which may be caused by HSV-2. Cases of panuveitis caused by HSV-2 in the adult population are very rare,2,4,5 so we thought it would be interesting to report a case of acute retinal necrosis in an adult male with a history of risky sexual practices.
A 32-year-old male who came to the emergency department for photopsies in the right eye. He had a history of hemifacial and left auricular herpes zoster 10 years earlier and recurrent herpes in the pinna. The patient was referred to neuro-ophthalmology and the case was classified as right optic neuritis. Laboratory tests showed normal results and cranial calcifications were observed with no pathological findings.
The patient returned to the emergency department 3 days later due to redness, pain and cloudy vision in the right eye. Optic neuritis similar to the previous episode was observed and hypertensive anterior uveitis was also diagnosed. Uveitis serologies were requested. He was discharged with treatment with cycloplegic eye drops 1 g/8 h, Alphagan® eye drops 1 g/12 h, Maxidex® eye drops 1 g/4 h, Valtrex® 500 mg/8 h, Septrin® 800-160 mg/12 h and usual analgesic if pain is present.
The patient returned after 4 days, with a worsening of visual acuity and the onset of intense vitritis and a whitish lesion in the peripheral retina. Serology only showed the presence of IgG for HSV-1/2; this, together with the clinical findings, led to a diagnosis of acute retinal necrosis of possible herpetic aetiology. The patient reported having had a risky sexual relationship 6 months earlier, but without herpetic genital lesions. The patient was admitted and treatment with intravenous acyclovir (10 mg/kg 3/day for 10 days) was initiated. Aqueous humour was obtained by intraocular puncture and subsequently sent to microbiology. Due to sample scarcity, the PCR was only performed for herpesviruses.
The patient improved with antiviral treatment and the presence of HSV-2 in the aqueous humour sample was confirmed at 48 h. Prophylactic argon laser treatment was performed on the healthy retina around the focus of peripheral retinal necrosis in the affected eye. The patient completed treatment at discharge with oral acyclovir 800 mg/5 times a day for 5 weeks and continued with maintenance therapy to prevent relapses and bi-lateralization with acyclovir 800 mg/8 h for 6 months. He was also treated with Dacortin® 30 mg/24 h for a month, currently continuing with a dose of 20 mg/24 h.
Herpetic eye infections can occur as a primary infection or by reactivation. After the initial infection, herpes will remain latent in the dorsal root ganglia of the body area where it occurred. In the case of HSV-2, the initial infection is almost always urogenital, and reactivations occur in this area, although most may be asymptomatic.1,3 However, HSV-2 reactivation can sometimes result in a short-lived viraemia and its arrival in a peripheral organ such as the central nervous system.3,5
In our case the patient had a history of facial and ear herpes for which no sample was processed, so it is not possible to know which type of herpes was the cause. The existence of a history of risky sexual practice could suggest that HSV-2 was acquired at this time and subsequently reactivated leading to viraemia and uveitis.4
Despite the severity of the case, the patient showed visual improvement and a good progression with intravenous acyclovir treatment, with no serious complications, coinciding with what has been described in the literature.3,4
Characterisation of the herpes virus involved in intraocular infections is very useful for understanding the aetiology and progression of these conditions, which can sometimes have serious consequences.
Conflict of interestsThe authors declare that they have no conflict of interest.
