|Year : 2019 | Volume
| Issue : 4 | Page : 316-318
Varicella zoster virus infection presenting with unilateral panuveitis
Suklengmung Buragohain, Dipankar Das, Puneet Misra, Prakhar Chaudhary, Shyam Sundar Das Mohapatra, Isha Agarwalla, Harsha Bhattacharjee
Department of Uveitis, Ocular Pathology and Neuro-ophthalmology Services, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
|Date of Submission||13-Oct-2019|
|Date of Acceptance||19-Nov-2019|
|Date of Web Publication||26-Dec-2019|
Dr. Suklengmung Buragohain
Sri Sankaradeva Nethralaya, Beltola, Guwahati - 781 028, Assam
Source of Support: None, Conflict of Interest: None
In this case report, we present a unique case of varicella zoster virus (VZV) infection that presented with unilateral panuveitis. The patient came with complaints of burning sensation of his left eye, and on examination, the presence of viral pocks over the face and trunk, anterior chamber cells and flare, and iritis were noted along with vitritis and retinitis and he was diagnosed as left eye VZV-associated panuveitis. VZV infection can present with panuveitis in rare occasions, and this is the first of its kind to be reported in India.
Keywords: Conjunctivitis, panuveitis, pocks, varicella
|How to cite this article:|
Buragohain S, Das D, Misra P, Chaudhary P, Das Mohapatra SS, Agarwalla I, Bhattacharjee H. Varicella zoster virus infection presenting with unilateral panuveitis. TNOA J Ophthalmic Sci Res 2019;57:316-8
|How to cite this URL:|
Buragohain S, Das D, Misra P, Chaudhary P, Das Mohapatra SS, Agarwalla I, Bhattacharjee H. Varicella zoster virus infection presenting with unilateral panuveitis. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2020 Aug 15];57:316-8. Available from: http://www.tnoajosr.com/text.asp?2019/57/4/316/273989
| Introduction|| |
Varicella zoster virus (VZV) is known to have a number of ocular involvements which can extend from skin lesions to retinal necrosis. There can be vesicular skin eruptions, conjunctival pocks, conjunctivitis, and corneal involvement, and most of these lesions are known to heal spontaneously. Along with the ocular surface involvement, there can also be uveitis, more commonly anterior uveitis, and panuveitis is known to be rare which is usually associated with acute retinal necrosis and progressive outer retinal necrosis (PORN) in immunocompromised cases.,
| Case Report|| |
A 49-year-old male presented with complaints of burning sensation in the left eye for 1 month, which was gradually increasing in intensity. The patient had no ocular history and medical history was positive for chicken pox infection 2 months back, essential hypertension, and diabetes mellitus. On general examination, there was presence of viral pocks without scar over the face and trunks [Figure 1] and [Figure 2]. On ocular examination, his visual acuity was 20/20 part in both the eyes (OU), and the intraocular pressure in the right (OD) and left eye (OS) was 17 and 19 mm of Hg, respectively. In the OS, slit-lamp biomicroscopy revealed the presence of conjunctivitis and pigments on the corneal endothelium and cells and flare of grade 1+ in the anterior chamber and iritis along with early cataractous changes of the lens [Figure 3]. Funduscopy showed the presence of vitritis with vitreous cells 2+ and a yellowish retinal lesion with areas of retinal degeneration in the superotemporal area of the retinal periphery, which was suggestive of retinitis. The OD had normal findings.
|Figure 1: Varicella zoster virus pock lesions over both sides of the face of the patient|
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|Figure 3: A slit-lamp photograph of the left eye showing conjunctivitis and anterior chamber flare|
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Based on the clinical findings, fundus fluorescein angiography (FFA) and high-resolution optical coherence tomography (OCT) were advised for OU along with tests for human immunodeficiency virus (HIV) 1 and 2, serum enzyme-linked immunosorbent assay (ELISA) titer for VZV, serum creatinine, postprandial, and fasting blood glucose measurement. The patient was also started on intravenous acyclovir 500 mg 8 hourly for 7 days, to be followed by oral valacyclovir (without oral steroids). In the left eye, FFA showed disc hyperfluorescence and paramacular retinal pigment epithelium defect [Figure 4]; no such thickness was seen on OCT. Test for HIV 1 and 2 was negative, serum creatinine was 0.9, fasting blood glucose was 148 mg/dL, and postprandial glucose was 206 mg/dL. The serum ELISA immunoglobulin G (IgG) titer for VZV was 731.70 mIU/mL, which was highly positive for the virus. Based on the clinical findings and investigations, the case was diagnosed as left eye varicella zoster infection-associated panuveitis. The patient was continued on IV acyclovir 500 mg with 100 mL of normal saline 8 hourly for 7 days. On the first follow-up day, which was after 2 days of presentation, the AC reaction had reduced and vitreous cells reduced from grade 2+ to 1+. After 5 days of treatment, there was no AC reaction and no vitreous cells and there was complete resolution of the inflammation.
|Figure 4: FFA image of the left eye showing disc hyperfluorescence and para-macular RPE defect|
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| Discussion|| |
This case was atypical due to the uncommon presentation of VZV infection. Although anterior uveitis is expected to be present along with retinochoroidal lesions, the presence of panuveitis was a rare finding in this case. To our knowledge, no previous case of panuveitis in an adult secondary to VZV infection has been reported in India.
The viral pock lesions over the face and trunk [Figure 1] and [Figure 2] suggested a recent varicella zoster infection, which was followed by the onset of an infectious uveitis. This was in contrast to a case reported by Belfair et al. of a 2-year-old child, in which panuveitis was the presenting feature of chicken pox. In our case, there was presence of anterior chamber inflammation, but it was not characteristic of a VZV-induced anterior uveitis as has been previously reported by Jap and Chee. The intraocular pressure was not elevated and there was no sign of iris atrophy or posterior synechiae.
Vitritis is uncommon in cases of VZV-induced uveitis, and it is usually associated with acute retinal necrosis. In our case, there was presence of vitritis, but it was in the absence of any features of acute retinal necrosis. On funduscopy, there was presence of a yellowish lesion with surrounding area of retinal degeneration superotemporally, which was suggestive of retinitis, and on FFA, a paramacular pigment epithelium defect was also present. VZV-associated retinal lesions include acute retinal necrosis, chorioretinitis, and PORN. Acute retinal necrosis is usually associated with granulomatous or nongranulomatous anterior chamber inflammation along with vitritis and full-thickness retinal necrosis. PORN can be described as a form of viral retinitis, which occurs due to VZV in immunocompromised states such as HIV/AIDS, and there is absence of anterior chamber inflammation and vitritis.
Laboratory investigation for serum IgG titer for VZV revealed high positivity, which was similar to a study conducted by Kezuka et al., in which they found that the serum antibody titer against VZV to be high in both the uveitis group and those with only skin lesions of VZV.
The patient was treated with only intravenous acyclovir, and steroids were avoided as there was history of diabetes. In spite of not using steroids, there was complete resolution of the inflammation with only acyclovir.
| Conclusion|| |
VZV can have a wide range of ocular involvement and uveitis is an important complication which can affect the visual morbidity significantly. Panuveitis is very rare in such cases, but it can be associated with retinal lesions which should be treated promptly to improve visual outcomes. To our knowledge, no previous case has been reported in India regarding VZV-induced panuveitis in an adult.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Sri Kanchi Sankara Health and Educational Foundation, Guwahati, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McCannel CA, Holland GN, Helm CJ, Cornell PJ, Winston JV, Rimmer TG. Causes of uveitis in the general practice of ophthalmology. UCLA community-based uveitis study group. Am J Ophthalmol 1996;121:35-46.
Jordan DR, Noel LP, Clarke WN. Ocular involvement in varicella. Clin Pediatr (Phila) 1984;23:434-6.
Belfair N, Levy J, Lifshitz T. Panuveitis as presenting sign of chickenpox in a young child. Can J Ophthalmol 2006;41:97-9.
Jap A, Chee SP. Viral anterior uveitis. Curr Opin Ophthalmol 2011;22:483-8.
Lin P. Infectious Uveitis. Curr Ophthalmol Rep 2015;3:170-83.
Kezuka T, Sakai J, Minoda H, Takeuchi M, Keino H, Streilein JW, et al
. A relationship between varicella-zoster virus-specific delayed hypersensitivity and varicella-zoster virus-induced anterior uveitis. Arch Ophthalmol 2002;120:1183-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]