Chickenpox-associated acute retinal necrosis syndrome

Varicella-zoster virus necrotising retinitis, retinal vasculitis and panuveitis following uncomplicated chickenpox in an immunocompetent child

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.

Varicella Zoster Virus-Associated Necrotizing Retinitis After Chickenpox in a 10-Year-Old Female: A Case Report

A necrotizing retinitis in children is a rare but vision-threatening ocular complication of chickenpox. We report a 10-year-old girl who developed chickenpox 1 month before presenting with panuveitis and necrotizing retinitis. After prompt antiviral treatment, her inflammatory signs were resolved. Early detection and treatment of varicella zoster-associated necrotizing retinitis after chickenpox can achieve good visual outcome.

Ocular involvement associated with varicella in adults

BACKGROUND

Varicella is a common infectious disease primarily of childhood that is usually benign and self-limited. It is, however, increasingly seen in adults who are at a higher risk of severe infection. Ocular complications of varicella are relatively uncommon and have been rarely described in adults. We describe herein five adults who developed ocular involvement in association with primary varicella-zoster virus infection.

FINDINGS

Ocular manifestations included acute anterior uveitis in four eyes, with associated stromal keratitis in one of them, epithelial ulcerative keratitis in the two eyes of one patient, and acute retinal necrosis in one eye. One patient with acute anterior uveitis was treated with topical steroids and cycloplegic agents. The four other patients received topical or systemic antiviral drugs, with subsequent resolution of acute ocular inflammatory disease.

CONCLUSIONS

The spectrum of chickenpox-associated ocular complications in adults is wide. Early diagnosis and appropriate management are mandatory to improve visual outcome.

Ischemic retinal vasculitis in an 18-year-old man with chickenpox infection

Ocular involvement after primary infection with varicella zoster virus is very rare. We report a case of a healthy 18-year-old man who presented with unilateral ischemic retinal vasculitis 10 days after the onset of chickenpox. He developed acute severe visual loss and a relative afferent pupillary defect in his right eye. Fundus imaging, optical coherence tomography, fundus fluorescence angiography, and electrophysiologic studies confirmed the diagnosis of retinal vasculitis, which led to generalized retinal ischemia. Although aggressive treatment with systemic steroids and antiviral drugs was administered, a poor visual outcome still resulted.

Uniocular anterior chamber inoculation of a tumor necrosis factor alpha-expressing recombinant of herpes simplex virus type 1 results in more rapid destruction and increased viral replication in the retina of the uninoculated eye

Tumor necrosis factor alpha (TNF-alpha) has been shown to have a protective role in the eyes and brains of herpes simplex virus type 1 (HSV-1)-infected mice. To determine whether overexpression of TNF-alpha affected the course of virus infection following uniocular anterior chamber inoculation, a recombinant of HSV-1 that produces TNF-alpha constitutively (KOSTNF) was constructed. BALB/c mice were injected with the TNF-alpha recombinant, a recombinant containing the pCI plasmid, a recombinant rescue virus, or the parental virus. Flow cytometry and immunohistochemistry were used to identify virus-infected cells and to determine the numbers and types of infiltrating inflammatory cells in the uninjected eyes. Virus titers were determined by plaque assay. There were no differences among the groups in virus titers or the route and timing of virus spread in the injected eyes or in the suprachiasmatic nuclei. However, in the uninjected eyes of KOSTNF-infected mice, TNF-alpha expression was increased and there were more viral antigen-positive cells and immune inflammatory cells. There was earlier microscopic evidence of retinal infection and destruction in these mice, and the titers of virus in the uninjected eyes were significantly increased in KOSTNF-infected mice on day 7 postinfection compared with those of KOSpCI-, KOS6beta rescue-, or KOS6beta-infected mice. The results suggest that instead of moderating infection and reducing virus spread, overexpression of TNF-alpha has deleterious effects due to increased inflammation and virus infection that result in earlier destruction of the retina of the uninoculated eye.

Acute retinal necrosis complicating chickenpox in a healthy adult--a case report and review of literature

Acute retinal necrosis (ARN) is known to occur in conjunction with primary varicella or chickenpox infection. The majority of ARN cases reported in the literature were of milder form with mild to moderate vitritis, limited retinitis, and rare occurrence of retinal breaks or detachment that responded well to intravenous acyclovir, with or without oral prednisolone. We report a case of unilateral ARN with marked vitritis and retinal necrosis leading to retinal breaks following chickenpox in a 32-year-old healthy lady. This patient was successfully treated with intravenous acyclovir followed by oral acyclovir and orbital floor triamcinolone injections to contain the inflammation with barrier laser therapy to secure the retinal breaks with good visual outcome. This case is unusual in its severity, and to our knowledge, orbital floor triamcinolone therapy was not used earlier to contain ARN inflammation.

Acute retinal necrosis complicating chicken pox in a healthy adult: a case report and review of literature

We report a case of unilateral acute retinal necrosis (ARN) with marked vitritis and retinal necrosis leading to retinal breaks following chicken pox successfully treated with intravenous acyclovir followed by oral acyclovir, orbital floor triamcinolone injections to contain the inflammation, and barrier laser therapy to secure the retinal breaks with good visual outcome. This case is unusual in its severity and the novel use orbital floor triamcinolone therapy to contain ARN inflammation.

Retinitis following varicella in a vaccinated child with acute lymphoblastic leukemia

Serious ocular disease following varicella (chickenpox) is rare in children. In addition, retinitis in children with hematologic malignancies may present a difficult diagnostic challenge because infectious retinitis may mimic leukemic involvement of the eye. We report a 7-year-old patient with T-cell acute lymphoblastic leukemia in remission who presented with visual complaints 2 weeks after developing chickenpox. Ophthalmologic evaluation revealed acute retinitis in the right eye. Prolonged therapy with acyclovir resulted in near complete recovery. Early diagnosis of VZV retinopathy and aggressive antiviral treatment is critical to prevent acute and long-term ocular sequelae.

Monitoring herpesvirus DNA in three cases of acute retinal necrosis by real-time PCR

BACKGROUND

It is not clear whether quantitative analysis of viral DNA in ocular specimens is correlated with disease activities of acute retinal necrosis (ARN).

OBJECTIVES

To monitor viral load in ocular specimens collected from patients with ARN by real-time polymerase chain reaction (PCR).

STUDY DESIGN

Ocular samples (aqueous humor and vitreous) were serially collected from three patients with ARN. Viral load in those samples was evaluated by real-time PCR.

RESULTS AND CONCLUSION

In case 1, large amounts of varicella zoster virus (VZV) DNA (4.8 x 10(6) to 5.5 x 10(6) copies/ml) were detected in aqueous humor during the first 2 weeks after admission. The viral load in vitreous was higher than that in aqueous humor at the time of vitrectomy. As ophthamoscopic findings and visual acuity improved through acyclovir (ACV) treatment, the viral load in aqueous humor decreased dramatically. In case 2, the patient was treated with intravenous ACV at first, but clinical features did not improve. The herpes simplex virus (HSV)-2 viral load in aqueous humor remained stable (2.3 x 10(3) to 2.8 x 10(3) copies/ml) during the first 3 weeks after admission. The amount of HSV-2 DNA in vitreous was again higher than that in aqueous humor. Although neither clinical features nor viral load had changed by ACV, intra-ocular ganciclovir (GCV) injection improved clinical features, and decreased viral load to undetectable levels. In case 3, the patient developed ARN within 1 month after the onset of varicella and demonstrated only mild clinical symptoms. She was treated with ACV administration alone and recovered quickly. In contrast to case 1, the copy number of VZV DNA at the time of admission was low (9 x 10(2) copies/ml), and decreased quickly in response to the treatment. Correlation between viral load in ocular specimens and clinical course of the disease was demonstrated in these patients.

Rétinites nécrosantes herpétiques

The diagnosis of necrotic herpetic retinitis is suggested on clinical grounds, prompting urgent appropriate intravenous and intravitreal treatment. PCR on ocular samples is most often successful in identifying the herpetic agent. Classic acute retinal necrosis syndrome caused by herpes simplex or zoster virus and the different clinical forms present in immunocompetent or immunodepressed patients are described. The differential diagnosis includes atypical presentation of retinal necrosis caused by toxoplasmosis, syphilis, or ocular lymphoma; the ocular samples are useful in establishing the etiological diagnosis. We describe the different therapeutic strategies in the acute phase and as secondary prophylactic treatment. The clinical outcome appears to be influenced by rapid, appropriate treatment, limiting the extension of the retinal necrosis.

Nécrose rétinienne aiguë : présentation clinique, modalités de prise en charge et pronostic à partir d’une série de 22 patients

PURPOSE

To evaluate the clinical outcome and medical management in a series of patients diagnosed with acute retinal necrosis.

MATERIAL AND METHODS

Between 1993 and 2000, 22 patients suffering from acute retinal necrosis were referred to our department. We retrospectively reviewed the clinical course, delay between diagnosis and first clinical manifestation, biological profiles, treatment and complications.

RESULTS

All patients had vitreous inflammation; retinitis was seen upon examination in 82% of the cases. Nevertheless, for six patients (27% of the cases), failure to recognize the diagnosis led to delay (mean, 5.5 days) between the first ophthalmological examination and antiviral therapy. Nineteen patients underwent laboratory evaluation, and virological diagnosis was made in 16 of them: varicella zoster virus was found in 11 cases, herpes simplex type 1 in three cases, and herpes simplex type 2 and cytomegalovirus in one case each. Nine patients were treated with a combination of aciclovir and foscarnet and 13 with aciclovir alone. Among the 16 patients who received aciclovir, one did not respond to therapy after 2 days and was cured only after foscarnet was added. Recurrence occurred at the end of treatment in only one patient. Retinal detachment complicated the course for 11 patients and was always associated with proliferative vitreoretinopathy. Among those, seven of the ten patients who accepted surgery were successfully treated. Eleven out of 22 patients had a final visual acuity up to 20/200 and two up to 20/40.

CONCLUSION

In our series, acyclovir alone was sufficient to cure the majority of cases. Even with antiviral therapy, the prognosis of acute retinal necrosis remains poor. Retinal detachment is the main complication.

Infiltration of T-lymphocytes in the brain after anterior chamber inoculation of a neurovirulent and neuroinvasive strain of HSV-1

Following anterior chamber (AC) inoculation of BALB/c mice with the KOS strain of herpes simplex virus type 1 (HSV-1), or with H129, a neuroinvasive and neurovirulent strain of HSV-1, both strains of virus spread from the injected eye through the brain to cause retinitis. However, KOS-infected mice develop retinitis in the uninoculated eye only, whereas H129-infected mice develop bilateral retinitis. Previous studies have shown that infiltrating T-cells in the suprachiasmatic nuclei (SCN) of the hypothalamus of KOS-infected mice concomitant with or before virus protect KOS-infected mice from ipsilateral retinitis. To determine the timing of T cell infiltration and cytokine production in the brain of H129-infected mice, adjacent, frozen sections of the brain were immunostained for virus, T-cells, IL-2, TNF-alpha or IFN-gamma. T-cells infiltrated the brains of H129-infected mice and cytokines were produced in infected tissues. However, virus spread to the optic nerve and retina of both the inoculated and uninoculated eye before T-cells and cytokines were detected in the SCN of H129-infected mice. These results suggest that infiltrating T-cells in the SCN of H129-infected mice may arrive too late to prevent the spread of virus into the optic nerves and retinas and thus prevent development of bilateral retinitis in infected mice.

Rapid spread of a neurovirulent strain of HSV-1 through the CNS of BALB/c mice following anterior chamber inoculation

Following uniocular anterior chamber (AC) inoculation of BALB/c mice with the KOS strain of herpes simplex virus type 1 (HSV-1), virus spreads from the injected eye to the ipsilateral suprachiasmatic nucleus (SCN) in the central nervous system (CNS) to infect the optic nerve and retina of the contralateral eye, and mice develop retinitis in that eye only. In contrast, after AC inoculation of BALB/c mice with the H129 strain of HSV-1, mice develop bilateral retinitis. The pathway(s) by which H129 spreads to cause bilateral retinitis is not known. To determine the route and timing of H129 spread after AC inoculation, BALB/c mice were injected in the AC of the right eye with 5 x 10(3) PFU of H129. Brains from 30 mice were sectioned on a brain matrix and the amount of virus in the brain and eyes was determined by plaque assay. Frozen sections were prepared from the eyes, brain, and trigeminal ganglia of an additional 30 mice, and HSV-1 antigen was detected by immunohistochemistry. After AC inoculation, H129 follows a pathway similar to KOS in the CNS, but H129 appears to spread more rapidly than KOS within the CNS. Unlike KOS, H129 is able to infect brain stem nuclei and H129-infected mice developed neurological impairments in addition to bilateral retinitis. The results of these studies suggest that the ability of H129 to spread rapidly in the CNS allows early virus infection of retino-recipient nuclei proximal to the contralateral and ipsilateral optic nerves. Early infection of retino-recipient nuclei, such as the SCN may allow virus to spread into the retinas before a virus-specific immune response can be induced.

Acute retinal necrosis syndrome in a child

We recently cared for an 11-year-old child with acute retinal necrosis syndrome, an ophthalmologic condition characterized by the triad of anterior uveitis, occlusive retinal vasculitis and progressive peripheral retinal necrosis. Acute retinal necrosis syndrome occurs primarily in nonimmunocompromised adults as a result of reactivated herpes simplex or varicella-zoster virus infection. Antiviral and antiinflammatory therapy appears to reduce the incidence of vision-threatening retinal necrosis and involvement of the contralateral eye.

Chickenpox in childhood. A review prepared for the UK Advisory Group on Chickenpox on behalf of the British Society for the Study of Infection

Chickenpox in childhood is a milder condition than in older patients, but serious and even fatal complications may occur. These occur especially in immunosuppressed individuals, but can also be seen in normal children. The commonest of these is secondary bacterial infection with staphylococci or streptococci. Reye's syndrome is now rare in chickenpox, since aspirin no longer used in treatment. Aciclovir and VZIG (varicella zoster immune globulin) have a role in the management of chickenpox in the immunosuppressed or immunodeficient child, and aciclovir may be valuable in managing some normal children. Chickenpox should not always be considered a trivial illness.

Progressive outer retinal necrosis (PORN) in AIDS patients: a different appearance of varicella-zoster retinitis

Retinal infections caused by the varicella-zoster virus (VZV) have been reported in immunocompetent and immunocompromised individuals. Two cases of a VZV-related retinitis are described with the characteristic features of the recently described progressive outer retinal necrosis (PORN) syndrome. Both patients suffered from the acquired immunodeficiency syndrome (AIDS) with greatly reduced peripheral blood CD4+ T lymphocyte counts, and presented with macular retinitis without vitritis. The disease was bilateral in one case and unilateral in the other. The clinical course was rapidly progressive with widespread retinal involvement and the development of rhegmatogenous retinal detachment with complete loss of vision in the affected eyes despite intensive intravenous antiviral therapy. VZV DNA was identified in vitreous biopsies, by molecular techniques based on the polymerase chain reaction (PCR), in both patients. At present, the use of very high-dose intravenous acyclovir may be the best therapeutic option in these patients for whom the visual prognosis is poor. Intravitreal antiviral drugs could also contribute to the management of these cases.

Acute retinal necrosis caused by reactivation of herpes simplex virus type 2

Acute retinal necrosis is a severe form of necrotizing retinitis. Acute retinal necrosis has been demonstrated to be caused by varicella-zoster virus and herpes simplex virus type 1. We treated three patients with acute retinal necrosis apparently caused by recrudescence of latent herpes simplex virus type 2. Primary viral infection was probably congenital, with documented perinatal herpes simplex virus type 2 infection in two patients. Bilateral chorioretinal scars were present in two patients, neither of whom had a history of ocular herpetic infection, suggesting that earlier subclinical chorioretinitis had occurred. In each case, periocular trauma preceded the development of retinitis by two to three weeks. These cases are evidently caused by trauma-induced reactivation of latent virus rather than the onset of a primary infection.