Unilateral varicella zoster virus ophthalmicus and contralateral acute retinal necrosis

Clinical course of von Szily reaction: Case report and comprehensive review of the literature

Purpose

To describe a rare case of von Szily reaction (VSR) accompanied by a comprehensive review of the literature.

Observations

A 57-year-old woman with herpes zoster ophthalmicus (HZO) associated with ipsilateral sectoral scleritis and anterior uveitis (sclerouveitis) subsequently developed contralateral necrotizing retinitis, leading to a diagnosis of VSR. A literature review revealed 10 additional cases of VSR. The full VSR cohort of 11 subjects included six women and five men, had a median age of 39 years (range 21–78 years), and most presented with HZO (n = 7, 63.6%), often associated with either ipsilateral anterior uveitis (n = 5; 45.5%) or keratitis (n = 4; 36.4%). All 11 cases developed necrotizing retinitis in the fellow eye, at a median of six weeks following onset in the sentinel eye. The most frequently implicated agent was varicella zoster virus (VZV; n = 8, 72.7%). A high proportion of the eight patients with VZV-associated VSR were identified as having increased risk of VZV reactivation, including age of 50 years or greater (n = 5, 62.5%), an underlying malignancy (n = 3, 37.5%), and/or use of immunosuppressive medication (n = 2, 25.0%).

Conclusion

This was the first reported case of VSR presenting as HZO-associated with sclerouveitis. A comprehensive literature review revealed that most previously reported cases presented with HZO associated with isolated anterior uveitis and/or keratitis, and that all reported cases of VSR developed necrotizing retinitis in the fellow eye, typically within two months of initial presentation. Patients with VZV-associated VSR often had known risk factors for VZV reactivation.

Two patients with the von Szily reaction: herpetic keratitis and contralateral retinal necrosis

PURPOSE

To present two patients with prior unilateral, herpetic keratitis who developed acute retinal necrosis (ARN) in the contralateral eye. These cases have noticeable similarities to the von Szily reaction. This describes the development of a contralateral retinitis subsequent to an anterior chamber injection of herpes simplex virus (HSV).

DESIGN

Interventional case series.

METHODS

Retrospective chart and literature review.

RESULTS

The first patient had neonatally acquired herpetic keratitis and developed ARN at age 21. Polymerase chain reaction of a vitreous biopsy detected HSV type-2 (HSV-2). The second patient was clinically diagnosed with ARN contralateral to varicella zoster keratitis. A detailed literature search located seven prior case reports with a von Szily reaction. These resembled our two cases except none had HSV-2 or years of latency from keratitis to retinitis.

CONCLUSIONS

Clinicians need to be cognizant of the von Szily reaction.