Fulminant bilateral acute retinal necrosis complicated with secondary herpes simplex type-1 viral encephalitis

Abstract

Rationale:Acute retinal necrosis (ARN), which is characterized by peripheral necrotizing retinitis, severe retinal arteritis, and progressive inflammatory reaction in the vitreous and anterior chambers, has been reported in cases with herpes simplex encephalitis (HSE). It is a relatively rare complication secondary to HSE. However, cases presented with viral encephalitis following ARN were seldom reported.Patient concerns:A 43-year-old immunocompetent male patient manifested the aforesaid reverse situation. He developed HSE following 3-day systemic steroid therapy for abrupt ocular pain and rapidly decreased visual acuity, which was later diagnosed as ARN. Polymerase chain reaction (PCR) analysis of vitreous specimen verified herpes simplex virus-1 (HSV-1) infection.Diagnosis:HSE associated with ARN.Interventions:The patient was treated with intravenous acyclovir (500 mg every 8 h) for 21 days. A pulse of intravenous methylprednisolone, 500 mg/d for 5 days was given as an anti-inflammatory therapy, followed by prednisone taper.Outcomes:The patient's neurological symptoms got improved very soon after the therapy, but his vision acuity remained no perception of light in both eyes.Lessons:The present case indicates that ARN can also be a risk factor for HSE. Once ARN was suspected, corticosteroid should be applied with caution and in combination with antiviral treatment to avoid progressive duplication of virus and its spread to the brain.

Uveo-meningeal syndrome secondary to Herpes Simplex Virus related acute retinal necrosis

“…This case is significant due to the very few documented accounts of HSV infection spreading from ARN to the brain. 12 , 15 Our literature review revealed four previous cases of patients who developed acute retinal necrosis due to HSV-1 and later went on to develop CNS infection. Three of the cases were found to have positive HSV-1 PCR testing on both vitreous and CSF samples, one of which was found on post-mortem testing.…”

“… 12 , 13 , 14 The fourth case report had positive HSV-1 PCR testing of a vitreous sample, however there was no mention of CSF PCR HSV testing. 15 Three of these patients had been receiving systemic steroids and one was chronically immunosuppressed.…”

Acute retinal necrosis by herpes simplex virus type 1: an unusual presentation of a primary infection

“…As far as we know, there is no reported case in the literature of ARN with or without meningitis/encephalitis as a first presentation of an HSV-1 infection. A recent case report has been published describing a rare presentation in a patient who first was diagnosed with ARN and posteriorly with encephalitis, but the authors do not specify if it represents a primoinfection 6…”

Acute retinal necrosis: pathophysiological aspects, diagnosis, and treatment

“…[22] Transmission of the virus from the brain to the eye and reactivation of a latent virus from the frontotemporal lobe and the optic chiasm is a presumed possible mechanism. [23][24][25] A study done on experimental models shows that a reverse mechanism from eye to brain is also possible. In these cases, the virus spreads from the affected eye to the central nervous system along the parasympathetic nerve fibres of the oculomotorius and HSV encephalitis develops within a few days after ARN.…”