Herpes simplex virus dissemination with necrotizing hepatitis following Descemet membrane endothelial keratoplasty

Abstract

Background Corneal transplants are the most common type of transplant and increasing in frequency. Donor cornea tissues are a rare source of herpes simplex virus (HSV) transmission and not routinely tested for presence of HSV. Donor graft-to-recipient transmission typically causes graft failure and anterior uveitis, and extra-ocular HSV disease has not been previously reported. We present a case of HSV transmission from donor cornea tissue that nearly cost the corneal transplant recipient his life. Case report An elderly immunocompetent man developed an acute illness 10 days after having donor corneal tissue implanted in a Descemet membrane endothelial keratoplasty (DMEK). He was found to have HSV necrotizing hepatitis per liver biopsy, trilineage cytopenia, rhabdomyolysis, acute kidney failure, altered mental status, early-stage hemophagocytic lymphohistiocytosis (HLH), and donor corneal tissue implant infection resulting in graft failure and anterior uveitis. HSV DNA was detected in cerebral spinal fluid, peripheral blood, explanted donor corneal tissue, and anterior chamber fluid (220 million HSV DNA copies per mL). HSV-1 seroconversion denoted a primary HSV infection, and the patient had no other risk factor for HSV acquisition. Early recognition of HSV dissemination prompting treatment with intravenous acyclovir, as well as a short course of HLH-directed therapy, resolved the systemic illness. Vision was restored to near normal by replacement of the infected corneal graft with new donor DMEK tissue in conjunction with intravitreal foscarnet treatment. Conclusion Awareness of the potential risk of donor cornea tissue transmitting HSV and leading to life-threatening HSV disease is paramount to early diagnosis and treatment. The role of donor cornea tissue in HSV transmission and disease merits additional attention and investigation.

Herpes simplex keratitis: A brief clinical overview

“…Tear fluid exosomes may be a site of HSV-1 Latency; involved in the spread of HSV-1 infection to human corneal epithelial cells (HCECs). Corneal grafts can also be a source of HSK infection if not properly screened[ 224 ]. With a global shortage of available viable cornea graft tissue, Li et al [ 225 ] demonstrated that porcine corneal tissue is a good option for human corneal tissue[ 225 ], Recurrent HSK has been implicated in Deep Anterior Lamellar Keratoplasty failure[ 226 ].…”

Enhanced Anti-Herpetic Activity of Valacyclovir Loaded in Sulfobutyl-ether-β-cyclodextrin-decorated Chitosan Nanodroplets

“…A relevant feature of these pathogens is the establishment a lifelong latent infection in neuronal cells that innervate the infected epithelium and periodical reactivation following various environmental cues. Genital herpes can cause severe or fatal infection in newborns through vertical congenital transmission from the mother to the infant [5,6] and can lead to severe complications in immunocompromised patients [7][8][9]. Of note, HSV-2 is strongly correlated to HIV infections [10,11].…”