Herpes simplex virus disease often misdiagnosed in children

Take home message: Herpes simplex virus in children is often diagnosed late or misdiagnosed, and children can experience visual loss due to complications or amblyopia.

By Vanessa Caceres; Reviewed by Juan Carlos Serna-Ojeda, MD

Mexico City-Although rare in children, herpetic simplex virus (HSV) is still a major cause of infectious corneal blindness-so, understanding how the disease functions in children is useful for clinicians, said Juan Carlos Serna-Ojeda, MD, Department of Cornea and Refractive Surgery, Instituto de Oftalmologia, Conde de Valenciana, Mexico City, Mexico

Dr. Serna-Ojeda summarized a recent retrospective record review that he and fellow researchers did at their ophthalmic referral center in Mexico City. The study, which was published in September in the journal Cornea, is the largest review of HSV information in children, Dr. Serna-Ojeda said.¹

Researchers analyzed the records of all children up to age 17 with herpes simplex infection in the anterior segment from 2002 to 2012. Patients who had atypical presentations and did not have their diagnosis confirmed by lab results were excluded.

Diagnosis was made via slit-lamp examination, clinical history, and sometimes with viral culture or polymerase chain reaction, Dr. Serna-Ojeda said.

There were 109 eyes of 103 patients included in the review. Six patients had bilateral simultaneous disease. Fifty-four patients were male, and the median age at presentation was 9 years old.

The median delay from symptom onset to presentation was 30 days. In 49 patients, a consultation was made because of red eye; other common reasons were presence of a white spot on the eye, tearing eye pain, low visual acuity, and photophobia.

Sixteen patients had actually been misdiagnosed before they arrived at the center for consultation. The disease was confused most often with bacterial keratitis, allergic conjunctivitis, bacterial conjunctivitis, and bacterial blepharoconjunctivitis, Dr. Serna-Ojeda said.

The median visual acuity at presentation was 20/80, with a range from 20/20 to light perception.

The most common single presentation of herpetic eye disease was dendritic epithelial keratitis (33 eyes) and interstitial stromal keratitis (34 eyes). The most common combined form of disease was blepharoconjunctivitis and epithelial keratitis (6 eyes).

Patients were most commonly treated with topical acyclovir (63 patients) followed by oral acyclovir (58 patients), Dr. Serna-Ojeda said. Thirty one patients had a prophylactic dose of acyclovir, and 16 patients never received acyclovir. Five children had an adverse effect from the medication, a mild change in renal function tests that returned to normal once they stopped using the drug, he said.

Of the 63 eyes diagnosed at Dr. Serna-Ojeda’s clinic, 18 had a recurrent case during follow-up. “In 24 eyes, it was considered to be a recurrence of a previously occurring illness,” he said.

In the full group of 109 eyes, 42 had recurrences of HSV. Those recurrences took place at an average of 15 months after the initial presentation.

The most common complications were corneal opacity, amblyopia, and residual astigmatism.

The median best corrected visual acuity was 20/40, with a range of 20/20 to counting fingers at 30 cm.

Dr. Serna-Ojeda said that the analysis shows herpetic disease in children is often diagnosed late or misdiagnosed. There also is an increased risk of vision loss and recurrence due to corneal complications and amblyopia, he said.

Reference

• Serna-Ojeda JC, Ramirez-Miranda A, Navas A, et al. Herpes simplex virus disease of the anterior segment in children. Cornea. 2015;34 Suppl 10:S68-S71.

Juan Carlos Serna-Ojeda, MD

E: juanc.sernao@gmail.com

This article was adapted from Dr. Serna-Ojeda’s presentation during the 2015 World Cornea Congress.