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Young man complains of blurred vision in left eye, fever and head pain
Stromal edema and punctate staining were found in the left eye on corneal examination.
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A 29-year-old man was referred from a general ophthalmologist for corneal evaluation after complaining of a “fog” in his left eye.
| Isabel Balderas | Tom Hsu, MD |
Two weeks prior, the patient described having a pain on the left side of his forehead, low-grade fever, chills and a bump on his left upper lid initially thought to be a bug bite. Around the same time, the patient complained of a sudden onset of blurriness in his left eye. The patient recalled that, at that time, he swam in a freshwater lake recently closed due to infestation of “rock snot” algae. The patient went to his ophthalmologist, and a left central corneal haze was noted as well as cellulitic changes around the left upper lid. The patient was started on topical moxifloxacin and cephalexin. A CT scan did not reveal orbital cellulitis. The patient’s left lid skin lesions improved, but his left eye continued to become more injected and light sensitive. The patient was then switched to oral amoxicillin, clavulanate sodium, valacyclovir and topical trifluridine and referred to the New England Eye Center for further workup.
Examination
On initial examination, the patient’s best corrected visual acuity was 20/20 in both eyes. IOP, pupillary and extraocular motility exams were unremarkable. Confrontation visual fields were full. Corneal sensation was intact in both eyes.
On slit lamp examination, a small, crusted lid lesion was seen near the margin of the left upper lid (Figure 1). The left cornea showed mild stromal edema and granular haze with keratic precipitates centrally, as well as punctate staining centrally (Figure 2). The left conjunctiva was moderately injected, and there was trace cell in the left anterior chamber. There were no iris abnormalities. The dilated fundus exam was unremarkable in both eyes.
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Images: Chen J, Wu HK |
What is your diagnosis?
Foggy vision, head pain
The differential diagnoses for this patient mainly involve infectious etiologies. Herpes simplex and herpes zoster virus can both cause stromal edema with an anterior chamber reaction, and although the classic signs of dendrites and pseudodendrites were not seen, it is not necessary for the diagnosis of herpetic keratouveitis. Bacterial and fungal keratitis appear to be consistent with the patient’s history of lid redness and swelling. Likewise, the patient’s recent swim in a freshwater lake should make Acanthamoeba a consideration, although the patient did not complain of severe eye pain. Topical anesthetic abuse and interstitial keratitis are lower on the differential diagnosis.
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Two new findings allowed us to make a more definitive diagnosis. First, upon further inquiry regarding the patient’s head pain, the patient described the pain as left-sided and outlined the dermatome of the V1 left trigeminal nerve. Second, days after initial presentation, the patient presented with pain localized to an area of a raised, erythematous scleral nodule in the left inferior sclera (Figure 3). The combination of the distribution of pain and scleritis led us to make the diagnosis of herpes zoster keratouveitis and scleritis.
Discussion
This case is an example of how different elements of a patient’s history can lead a clinician toward an incorrect diagnosis. The patient’s initial history of an eyelid skin lesion, periorbital cellulitis and corneal involvement makes bacterial keratitis a strong possibility, and the patient was treated with topical and oral antibiotics at first. However, further questioning revealed the precise distribution of the head pain, consistent with herpes zoster neuralgia. Scleritis, although most often seen in association with autoimmune connective tissue diseases, can occur in a number of infections, including Lyme disease, tuberculosis, syphilis, cat scratch disease and herpes zoster. A number of studies, including CBC, LFT, uric acid, FTA-ABS, Lyme, UA, HLA B27, ANA, p-ANCA and c-ANCA, and a chest X-ray were all negative, which again suggests herpes zoster as the logical diagnosis.
The patient was started on prednisolone drops in his left eye while he continued to take valacyclovir, amoxicillin and clavulanate sodium. Ibuprofen was given for his scleritis, and on further follow-up, both his scleritis and his stromal edema improved. Because of the patient’s young age and gender, searching for risk factors for immunodeficiency is warranted; however, the patient was lost to follow-up before he could be tested.
For more information:
- John Chen, MD, and Helen K. Wu, MD, can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com
- Edited by Isabel M. Balderas, MD, and Tom Hsu, MD. Drs. Balderas and Hsu can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com. Drs. Balderas and Hsu have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.
Reference:
- Liesegang TJ. Herpes zoster virus infection. Curr Opin Ophthalmol. 2004;15(6):531-536.