Bilateral Herpes Simplex Keratitis Presenting as Bilateral Ulcerative Blepharo-Keratoconjunctivitis: A Rarity or Pattern

Abstract

We report a case of an immunocompetent 77-year-old Caucasian female presenting with bilateral herpes simplex keratitis masquerading as bilateral ulcerative blepharo-keratoconjunctivitis. Most cases of herpes simplex keratitis present unilaterally and uncommon occurrences of bilateral cases range from 1.3% to 10.9%. In literature, bilateral herpes simplex keratitis has been reported for patients with atopic disease, corticosteroid use, autoimmune diseases, and UV A light exposure. Our patient had none of these conditions, but she did suffer from type 2 diabetes mellitus that was well-controlled. She had no prior history of known herpes simplex disease and tested negative for COVID 19. To date, this is the third reported bilateral herpes simplex keratitis case and the second reported in an elderly patient with shared history of prostaglandin usage and presence of diabetes mellitus. Our rationale for reporting this case is that while it seems to be a rare presentation it could be establishing a pattern. The study explores the relationship between a prostaglandin and HSV activation that may allow viral entrance due to epithelial breakdown. Since our patient did not have any of the previously reported immunocompromised states that have been associated with bilateral herpes keratitis, this case may represent a new pattern for HSV infection. Our clinical methods indicate that close follow-up was crucial to identifying the patient's eye condition as a bilateral herpes simplex keratitis. Due to this potential pattern of disease, a revised management approach may benefit similar patients by selecting alternative treatments for glaucoma early in the disease presentation.

Incidence and Risk Factors of Bilateral Herpetic Keratitis: 2022 Update

“…On the slit-lamp examination, epithelial keratitis presents as a dendritic lesion with terminal buds, swollen borders and intraepithelial cell infiltration. The ulcer may progressively increase in size to give a "geographical" or "amoeboid" configuration [2,5,9], especially in patients with local or systemic immunosuppression.…”

“…Similarly, the necrotizing form appears as gray-white or opaque, but there is accompanying necrosis and ulceration on slit-lamp examination. Edema and abscess may be apparent as well [2,9]. It can often result to perforation [13].…”

“…Herpetic keratitis is the result of a corneal infection with Herpes Simplex Virus (HSV) and it is recognized as a leading cause of corneal blindness worldwide [1,2]. Bilateral HSV keratitis consists of simultaneously occurring infection in both eyes.…”

“…While Herpes Simplex Virus (HSV) can infect any part of the body and elicit a variety of serious diseases in humans, it commonly infects the face, genitals and eyes with skin/face infections, typically a consequence of either oral or ocular infection [1,2]. The virus is most commonly transmitted by droplets of infected secretions, such as tears and saliva, or by direct contact of skin sores [2,[4][5][6]. It was previously thought that HSV-1 had a predilection for the trigeminal ganglion and HSV-2 for the sacral ganglion [4,6].…”

“…It was previously thought that HSV-1 had a predilection for the trigeminal ganglion and HSV-2 for the sacral ganglion [4,6]. However, ocular infection can be caused by both HSV-1 and HSV-2 [2,3]. Corneal infection is due to direct inoculation.…”