Herpes Simplex Keratitis in Patients with SARS-CoV-2 Infection: A Series of Five Cases

Abstract

Herpes simplex virus type 1 (HSV-1) is a leading cause of infectious blindness worldwide. Most of the initial infection cases manifest as acute epithelial keratitis. Reactivation of herpesviruses is common in critically ill patients, including patients with severe Coronavirus disease (COVID-19). However, the data on COVID-19-related ocular infections is sparse, despite recent observations that more than 30% of COVID-19-infected patients had ocular manifestations. We report five cases of HSV-1 keratitis in COVID-19 patients. In total, five COVID-19 patients underwent ophthalmic examination, showing similar symptoms, including photophobia, tearing, decreased vision, eye redness, and pain. After initial assessment, tests of visual acuity and corneal sensitivity, a fluorescein staining test, and complete anterior and posterior segment examinations were performed. A diagnosis of HSV-1 keratitis was confirmed in all cases. Therapy was initiated using a local and systemic antiviral approach together with local antibiotic and mydriatic therapy. The complete reduction of keratitis symptoms and a clear cornea was achieved in all patients within 2 weeks. SARS-CoV-2 infection may be a risk factor for developing HSV-1 keratitis, or it may act as a potential activator of this ocular disease.

Herpes Simplex Virus Re-Activation in Patients with SARS-CoV-2 Pneumonia: A Prospective, Observational Study

“…The authors suggested lymphopenia as the probable cause of the increased incidence of Herpesviridae re-activation, without considering the use of steroids or tocilizumab [ 13 , 14 ]. Regarding patients in non-ICU wards, only case reports on skin, oral, and ocular Herpesviridae clinical manifestations in patients with COVID-19 were published [ 15 , 16 , 17 , 18 ].…”

Atypical Presentation of Herpes Simplex 1 Virus in a COVID-19 Patient

“…1,2 Whilst hypertrophic manifestations are well described in HSV 2 genital infections, they are extremely rare in HSV 1 infections. 3 In this patient, we believe the severe COVID-19 disease together with the prolonged course of corticosteroids and the short and underdosed initial course of acyclovir enabled the development of this atypical lesion, explained recurrence immediately after suspension of the antiviral drug. In a case series reporting five cases of HSV 1 keratitis in COVID-19 patients, the authors postulated that the decline in NK cells and CD8+ T cells found in SARS-CoV-2 infections could play a role in potentiating the reactivation of HSV 1.…”

Stromal and endothelial herpes simplex virus keratitis reactivation in the convalescent period of COVID-19 – A case report

“…Bilateral conjunctivitis, an ophthalmic HSV infection, was reported in a 69-year-old Caucasian male with moderate COVID-19 disease. [ 6 ] In a case series described by Majtanova et al ,[ 10 ] five cases (two of them bilateral) of keratitis were found among COVID-19–positive patients during the SARS-CoV-2 pandemic in Slovakia, where they also found 2–2.5 times higher incidence of HSV keratitis in that period and suspected COVID-19 as a potential activator of these five cases. All of their cases had associated epithelial keratitis, whereas our case presented with no epithelial ulcer.…”