Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 536
  • Home
  • Print this page
  • Email this page

   Table of Contents      
PHOTO ESSAY
Year : 2020  |  Volume : 68  |  Issue : 9  |  Page : 1953-1955

A rare presentation of an atypical herpes simplex virus retinitis in an immunocompetent patient following an episode of fever


1 Medical Research Foundation, Sankara Nethralaya, Kolkata, West Bengal, India
2 Medical Research Foundation, Sankara Nethralaya, Chennai, India
3 Vision Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission11-Apr-2020
Date of Acceptance29-May-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Dr. S Sudharshan
Medical Research Foundation, 18, College Road, Sankara Nethralaya, Chennai - 600 006, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_942_20

Rights and Permissions
  Abstract 


Keywords: Atypical retinitis, HSV, Post-fever retinitis, Acyclovir, Polymerase chain reaction


How to cite this article:
Kumar A, Nair N, Sudharshan S, Malathy J, Biswas J. A rare presentation of an atypical herpes simplex virus retinitis in an immunocompetent patient following an episode of fever. Indian J Ophthalmol 2020;68:1953-5

How to cite this URL:
Kumar A, Nair N, Sudharshan S, Malathy J, Biswas J. A rare presentation of an atypical herpes simplex virus retinitis in an immunocompetent patient following an episode of fever. Indian J Ophthalmol [serial online] 2020 [cited 2020 Sep 23];68:1953-5. Available from: http://www.ijo.in/text.asp?2020/68/9/1953/292597



A 20-year-old male, presented with sudden onset decreased vision (DV) in both eyes (OU) since one week. He had a history of having been treated elsewhere for fever and cervical lymphadenopathy 15 days back with complete resolution. Best corrected visual acuity (BCVA)-OU was counting fingers close to face (CFCF). Slit lamp examination-OU revealed anterior chamber reaction-2+, vitreous cells-2+ with normal intraocular pressure (IOP). Fundus-OU revealed normal optic disc, dull foveal reflex, and multiple sinusoidal outer retinal lesions arising from the disc upto mid-periphery with intraretinal hemorrhages [Figure 1]a and [Figure 1]b. Investigations including blood smear, serology for syphilis, toxoplasmosis, human immunodeficiency virus (HIV), chest X ray and mantoux test were all normal. Other possible causes of post-fever retinitis were ruled out. Aqueous humor (AH) polymerase chain reaction (PCR) was positive for herpes simplex virus-2 (HSV-2) genome and negative for others. Fluorescein angiography (FA) showed normal choroidal and early arterial phase, perivascular leakage, and disc staining in the recirculation and late stage [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f. He was initiated on intravenous (IV) acyclovir 500 mg, 8th hourly for 10 days followed by oral acyclovir which was continued for 6 weeks along with tapering dose of oral prednisolone. At 1 week, lesions showed early signs of resolution [Figure 3]a and [Figure 3]b. At 3 weeks follow-up, BCVA-OU was maintained at CFCF. Anterior segment was quiet, fundus showed healed lesions with disc pallor [Figure 4]a and [Figure 4]b. Visual evoked potential revealed delayed latency suggestive of an early onset optic neuropathy. Magnetic resonance imaging (MRI) brain was unremarkable. At 3-month follow-up, ocular and systemic condition was stable.
Figure 1: (a) Color fundus montage photograph of the right eye showing distinct ribbons of sinusoidal outer retinal lines radiating outwards from the posterior pole appearing like a “White oak leaf” distinct from the retinal vessels and involving the fovea. There is loss of foveal reflex. (b) Color fundus montage photograph of the left eye showing a similar pattern and distribution of radiating white lines. There is evidence of a small segment of perivascular cuffing seen along the inferior retinal vein. There is loss of foveal reflex suggestive of macular edema

Click here to view
Figure 2: (a-f) Fundus fluorescein angiography (FFA) images. Right eye: FFA Choroidal phase (a) shows normal study. The nasal midperiphery shows a faint perivascular leakage in the recirculation phase (b). The late stage shows minimal perifoveal staining and disc staining (c). Left eye: FFA late arterio-venous (d) shows normal study. Nasal midperiphery shows a faint perivascular leakage in the recirculation phase (e). The late phase shows minimal perifoveal staining and disc staining (f)

Click here to view
Figure 3: Right eye (a) and Left eye (b) montage color fundus picture while on treatment (one week review) showing the fading of the outer retinal lines appearing as radiating artefactual bands

Click here to view
Figure 4: Right eye (a) and Left eye (b) montage color fundus picture at 3 weeks follow-up on treatment showing resolution of the retinal transparency with complete disappearance of the outer retinal lines and restoration of the foveal reflex. Note – absence of residual pigmentary changes in the retinal pigment epithelium (RPE) and significant optic disc pallor.

Click here to view



  Discussion Top


Our patient, a young immunocompetent male with atypical HSV-2 retinitis post-fever, did not fit into any of the reported manifestations associated with non-necrotizing herpetic retinitis (NNHR) or post-fever retinitis.[1],[2],[3],[4] Serpiginoid pattern of lesions, commonly described with TB, is reported uncommonly with herpes viruses.[5] Investigations ruled out TB. Our case indicates that herpetic retinitis can present in phenotypic patterns not commonly described in literature and PCR can be diagnostic in such situations.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee JH, Agarwal A, Mahendradas P, Lee CS, Gupta V, Pavesio V, et al. Viral posterior uveitis. Surv Ophthalmol 2017;62:404-45.  Back to cited text no. 1
    
2.
Tran TH, Stanescu D, Caspers-Velu L, Rozenberg F, Liesnard C, Gaudric A, et al. Clinical characteristics of acute HSV-2 retinal necrosis. Am J Ophthalmol 2004;137:872-9.  Back to cited text no. 2
    
3.
Bodaghi B, Rozenberg F, Cassoux N, Fardeau C, Lehoang P. Nonnecrotizing herpetic retinopathies masquerading as severe posterior uveitis. Ophthalmology 2003;110:1737-43.  Back to cited text no. 3
    
4.
Vishwanath S, Badami K, Sriprakash KS, Sujatha BL, Shashidhar SD, Shilpa YD. Post-fever retinitis: A single center experience from south India. Int Ophthalmol 2014;34:851-7.  Back to cited text no. 4
    
5.
Nazari Khanamiri H, Rao NA. Serpiginous choroiditis and infectious multifocal serpiginoid choroiditis. Surv Ophthalmol 2013;58:203-32.  Back to cited text no. 5
    


    Figures

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



 

Top
 
 
  Search
 
    Similar in PUBMED
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Discussion
References
Article Figures

 Article Access Statistics
    Viewed303    
    Printed1    
    Emailed0    
    PDF Downloaded61    
    Comments [Add]    

Recommend this journal