Petal-shaped herpetic dendritic keratitis in an immunosuppressed patient

INTRODUCTION

A 45-year-old male presented with complaints of pain, redness, and watering in the right eye for the past 7 days. He has a recent diagnosis of mixed connective tissue disease, aseptic meningitis, and suspected central nervous system vasculitis, for which he has been receiving systemic immunosuppression, including oral prednisolone, mycophenolate mofetil, and hydroxychloroquine, for the past 1 month. He was positive for autoimmune markers such as anti-Ro-52 and anti-PM/Scl antibodies. On clinical examination, the best-corrected visual acuity in the right eye was 6/9, and the intraocular pressure was 18 mmHg. Slit-lamp examination revealed two central petaloid-shaped dendritic epithelial lesions on the cornea and two small healing lesions with scalloped margins located paracentrally and another one healing lesion near the limbus at the 5 o’clock position. The lesions stained positively with fluorescein under a cobalt blue filter as shown in the figure 1. No anterior chamber reaction was noted. Corneal sensation was decreased in the right eye compared to the left eye. Examination of the left eye was unremarkable. A clinical diagnosis of herpetic epithelial keratitis in the right eye was made, likely precipitated by systemic immunosuppression. The patient was started on topical ganciclovir ophthalmic ointment 0.15% 5 times daily and moxifloxacin 0.5% eye drops 4 times daily.

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Figure 1:

Slit-lamp image showing multicentric herpetic epithelial keratitis. Two central lesions display a characteristic petal-shaped dendritic pattern, while two paracentral lesions appear as healing ulcers with scalloped margins. Another healing lesion is noted near the limbus at the 5 o’clock position.

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DISCUSSION

Herpetic keratitis is a common, debilitating ocular condition caused by herpes simplex virus type 1 and type 2, affecting up to two-thirds of the global population at some point in their lives.^[1]

Following the primary infection, the virus remains latent in the dorsal root ganglia and may reactivate in response to triggers such as stress, uncontrolled diabetes, or systemic immunosuppression.^[1-3] Reactivation can result in a spectrum of corneal manifestations, including herpetic epithelial, stromal, and endothelial keratitis, as well as keratouveitis.^[1-3] In the present case, systemic immunosuppression may have contributed to viral reactivation and corneal involvement. Treatment of herpetic epithelial keratitis typically includes topical antiviral agents such as acyclovir 3% ointment or ganciclovir 0.15% gel, applied 5 times daily for 1 week and then tapered to 3 times daily for another week.^[1-3] For patients with recurrent episodes, prophylactic oral acyclovir 400 mg twice daily is recommended, with regular monitoring of renal function.^[1-3]

CONCLUSION

This case highlights the risk of herpetic epithelial keratitis in immunosuppressed patients as a potential complication. Warning signs needs to be explained to the patients who are going to receive immunosuppression for a long time. Prompt diagnosis and antiviral treatment are crucial to prevent further ocular morbidity.