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BRIEF COMMUNICATION
Year : 2010  |  Volume : 58  |  Issue : 1  |  Page : 64-66

Coin-shaped epithelial lesions following an acute attack of erythema multiforme minor with confocal microscopy findings


Vittala International Institute of Ophthalmology & Prabha Eye Clinic and Research Center, Bangalore, India

Date of Submission03-Nov-2008
Date of Acceptance30-Dec-2008
Date of Web Publication22-Dec-2009

Correspondence Address:
Kalpana Babu
Prabha Eye Clinic & Research Centre, 504, 40th cross, Jayanagar 8th block, Bangalore - 560 070
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.58475

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  Abstract 

We report an interesting ocular finding of bilateral multiple coin-shaped epithelial lesions along with the confocal microscopy findings in a patient following an acute attack of erythema multiforme (EM) minor. A 30-year-old male presented with a history of watering and irritation in both eyes of three days duration. He was diagnosed to have EM minor and was on oral acyclovir. Slit-lamp examination revealed multiple coin-shaped epithelial lesions. Confocal microscopy showed a corresponding conglomerate of hyper-reflective epithelial lesions. The corneal lesions resolved over six weeks with oral steroids and acyclovir. An immunological mechanism is suspected.

Keywords: Coin-shaped epithelial lesions, confocal microscopy, erythema multiforme minor


How to cite this article:
Babu K, Murthy VR, Akki VP, Prabhakaran VC, Murthy K R. Coin-shaped epithelial lesions following an acute attack of erythema multiforme minor with confocal microscopy findings. Indian J Ophthalmol 2010;58:64-6

How to cite this URL:
Babu K, Murthy VR, Akki VP, Prabhakaran VC, Murthy K R. Coin-shaped epithelial lesions following an acute attack of erythema multiforme minor with confocal microscopy findings. Indian J Ophthalmol [serial online] 2010 [cited 2019 Aug 21];58:64-6. Available from: http://www.ijo.in/text.asp?2010/58/1/64/58475

Ocular manifestations following Steven-Johnson's syndrome (SJS) is common and have been well-described in literature. [1],[2] However, ocular manifestations following an attack of erythema multiforme (EM) minor is rare. [1] We report an interesting ocular finding of multiple coin-shaped epithelial lesions along with the confocal microscopy findings following an acute attack of EM minor.


  Case Report Top


A 30-year-old male presented to us with a history of watering and irritation in both eyes of three days duration. He was diagnosed to have EM minor following an attack of viral fever with skin eruptions on the face, arms and legs along with shallow, aphthous ulcers, one week back. There was no history of any drug intake leading to the fever and occurrence of skin eruptions. The erythrocyte sedimentation rate (ESR) was 42 mm/h and the total white blood count was 12,000 cells/mm 3 with predominant neutrophils (72%). Routine urine examination was normal. Blood and urine cultures were negative for bacteria and fungi. Chest X-ray was normal. Antinuclear antibody and rheumatoid factor were negative. He was on oral acyclovir 800 mg five times/day, started by his treating dermatologist, given for a total of seven days.

On examination, he had papular skin eruptions on the face, arms and legs with two shallow painful ulcers in the buccal mucosa [Figure 1]. His best-corrected visual acuity was 20/20 in both eyes. Slit-lamp examination in both eyes revealed multiple coin-shaped epithelial lesions, some showing central clearing [Figure 2] A, B. There was no involvement of the stroma. Corneal sensation (tested with wisp of cotton) was normal. Rest of the anterior segment, intraocular pressures and fundus examination were normal. Confocal microscopy (HRT II, Rostock corneal module, Heidelberg, Germany) showed conglomerates of hyper-reflective epithelial cells corresponding to the coin-shaped epithelial lesions [Figure 3]. The subepithelial nerve plexus, the stroma and endothelium were normal. He was started on oral prednisone, 60 mg/day slowly tapered by 10 mg/day over six weeks along with ocular lubricants (1% carboxymethyl cellulose eye drops, four times a day). The skin and corneal lesions [Figure 4] resolved over six weeks. Repeat confocal microscopy showed normal epithelial cells, subepithelial nerve plexus, stroma with keratocytes and endothelium.


  Discussion Top


Erythema multiforme is an acute mucocutaneous hypersensitivity reaction characterized by a skin eruption, with or without oral or other mucous membrane lesions. EM has been classified into a number of different variants based on the degree of mucosal involvement and the nature and distribution of the skin lesions. EM major (toxic epidermal necrolysis) is more severe, typically involving two or more mucous membranes with more variable skin involvement - which is used to distinguish it from SJS, where there is extensive skin involvement and significant mortality and morbidity of 5-15%. [3] These features are considered to be sequelae of a cytotoxic immunologic attack on keratinocytes expressing non-self antigens. These antigens are primarily microbial (viral or bacterial infection) or drugs. [3] Cytotoxic effector cells, CD8 + T lymphocytes in the epidermis, induce apoptosis of scattered keratinocytes and lead to satellite cell necrosis.

On the other hand, EM minor typically affects no more than one mucosa, is the most common form and may be associated with symmetrical target lesions on the extremities. Herpes simplex virus-induced EM minor constitutes 15-60% of EM minor. The treatment is a combination of acyclovir and oral steroids. [3]

Ocular involvement in EM minor is rare. Unlike SJS, ocular findings in EM minor have not been very well-described in literature (Medline search). [1],[2],[4],[5] We report an interesting ocular finding of coin-shaped lesions with some lesions showing central clearing confined to the epithelium of the cornea with no involvement of the underlying nerves or the stroma. Confocal microscopy findings show conglomeration of hyper-reflective lesions in the epithelium. The disappearance of these lesions following treatment is also documented on confocal microscopy. A probable immunological reaction targeted against the epithelial cells in the epithelium is speculated.


  Conclusion Top


In this case report, an interesting ocular finding of coin-shaped epithelial lesions with central clearing along with the confocal microscopy findings is reported in a patient following an acute attack of EM minor.

 
  References Top

1.
Power WJ, Ghoraishi M, Merayo-Lloves J, Neves RA, Foster CS. Analysis of the acute ophthalmic manifestations of the erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis disease spectrum. Ophthalmology 1995;102:1669-76.   Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.
Chang YS, Huang FC, Tseng SH, Hsu CK, Ho CL, Sheu HM. Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis: Acute ocular manifestations, causes, and management. Cornea 2007;26:123-9.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.
Farthing P, Bagan JV, Scully C. Mucosal disease series. Number IV. Erythema multiforme. Oral Dis 2005;11:261-7.  Back to cited text no. 3
    
4.
Sotozono C, Ang LP, Koizumi N, Higashihara H, Ueta M, Inatomi T, et al. New grading system for the evaluation of chronic ocular manifestations in patients with Stevens-Johnson syndrome. Ophthalmology 2007;114:1294-302.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.
De Rojas MV, Dart JK, Saw VP. The natural history of Stevens Johnson syndrome: Patterns of chronic ocular disease and the role of systemic immunosuppressive therapy. Br J Ophthalmol 2007;91:1048-53.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
1 Reply: Coin-shaped epithelial lesions following an acute attack of erythema multiforme minor with confocal microscopy findings
Babu, K., Murthy, V.R., Akki, V.P., Prabhakaran, V.C., Murthy, K.R.
Indian Journal of Ophthalmology. 2011; 59(2): 167
[Pubmed]
2 Corneal lesions in erythema multiforme minor - Are systemic steroids indicated
Jain, S., Rathore, M.K., Dwivedi, P.C., Tirkey, E.
Indian Journal of Ophthalmology. 2010; 58(6): 559-560
[Pubmed]



 

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