Acute bilateral granulomatous anterior uveitis as an extra-hepatic manifestation of hepatitis A virus (HAV) infection: a case report

Abstract

Anterior uveitis (AU) is the most common form of uveitis. The differential diagnosis of AU is broad, ranging from infectious etiologies to autoimmune causes. However, approximately half remain idiopathic. Infections are the vision-threatening causes of AU which should be ruled out by history taking and detailed physical examination combined with guided work up. We report a rare case of bilateral granulomatous AU following hepatitis A virus (HAV) infection in an immunocompetent patient. A 35-year-old male presented to our center with a chief complaint of pain and redness in both eyes 3 days prior to the presentation. The patient's medical and drug history was unremarkable. He had a history of river water consumption 20 days prior to presentation. The patient was diagnosed with acute bilateral granulomatous AU. All routine work up to investigate the etiology of the disease was unremarkable, except for the serology of acute HAV infection, which was positive. The patient was managed with the topical steroid and cycloplegic for 2 weeks with no recurrence at one-year follow up. Extra-hepatic complications of HAV were reported in previous studies including arthritis, urticaria, myocarditis, nephritis, and myositis. The mechanism of extra-hepatic complication of hepatitis A is unknown; however, immune-complex deposition is most likely the etiological cause. Our report represents a rare case of sudden onset with limited duration granulomatous AU as a presenting manifestation of HAV infection. Previous studies do not provide a direct evidence of granulomatous AU associated with the HAV infection.

Recent advances in hepatitis A virus research and clinical practice guidelines for hepatitis A virus infection in Japan

“…Cardiomyopathy and myocarditis following HAV infection were also reported 162–164 . Uveitis, arthritis, and acute pancreatitis may also be associated with HAV infection 165–168 …”

“…[162][163][164] Uveitis, arthritis, and acute pancreatitis may also be associated with HAV infection. [165][166][167][168] Thus, attention should be paid to the extrahepatic manifestation associated with hepatitis A.…”

Local and systemic autoimmune manifestations linked to hepatitis A infection

“…The development of AIH may occur in genetically susceptible people exposed to a number of environmental triggering factors such as viruses, including the HAV, xenobiotics, and drugs (16). Interestingly the presence of the HLA DRB1*1301 allele has been associated with slow HAV clearance and autoantibodies expression among Brazilian and Argentinian children with hepatitis A; HLA DRB*1301 allele, an indicator for AIH, is related with persistent liver damage after HAV infection in both pediatric and arthritis, glomerulonephritis, neurological pathologies (mononeuritis multiplex, transverse myelitis, Guillain-Barré syndrome) as well as cryoglobulinemia and vasculitis (5)(6)(7)(8)(9)(10)(11)(12)(13).…”

“…Hepatitis A may be also linked with adult-onset Still's disease development, a multi-genic systemic that the action is mediated also via a not well elucidated autoimmune mechanism (8).…”

Immune disorders and rheumatologic manifestations of viral hepatitis

“…Isolated cases of uveitis associated with hepatitis A have also been described[ 32 , 33 ]. Moreover, uveitis appeared before the symptoms of hepatitis[ 32 ].…”