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Multiple parallel-line endotheliitis may have herpetic origin
Serological testing could confirm the diagnosis of this rare entity.
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Multiple parallel-line endotheliitis may represent a mild and atypical variant of herpes simplex keratitis, according to a recent study.
An 89-year-old woman presented with multiple, primarily horizontal, lines of keratic precipitates on the entire endothelium (MPLE) of her left eye; the presumed diagnosis was idiopathic endotheliitis. She responded to topical steroid prednisolone acetate 1% three times a day, with complete resolution 1 week after the initial presentation. A blood sample was sent for herpes simplex virus (HSV) and varicella zoster virus serology.
The patient tested positive for immunoglobulin G and immunoglobulin M titers for HSV. Serological findings were consistent with reactivation of, or recent infection with, HSV.
Zia I. Carrim, FRCOphth, the study’s co-author, told Primary Care Optometry News in an interview that although this patient was treated with a topical steroid, “we would advocate the use of a topical antiviral as well, having established a possible link with HSV.”
Carrim said this also conforms with what is considered to be a more classical picture of herpetic endotheliitis, or disciform keratitis.
“Serological tests based on venous blood are relatively safer and noninvasive compared to sampling aqueous humor,” Carrim said. “To be more confident in saying that there is a definite association between HSV and MPLE, we would need to establish similar serological findings across many more cases.”
In 2008, Hori and colleagues published three cases of idiopathic MPLE, but serological testing was not performed. One patient underwent aqueous sampling but no herpes simplex virus 1, varicella zoster virus or cytomegalovirus could be detected by reverse transcriptase polymerase chain reaction.
“Unlike Hori, we also considered serology for herpetic disease,” Carrim said. “We’ve raised the possibility of an atypical variant of herpes simplex keratitis; if future prospective studies or larger case series prove us right, then we would have made a small contribution towards a better understanding of MPLE.”
In 1985, Robin and colleagues reported progressive endotheliitis associated with HSV-1 uveitis with a line of keratic precipitates at the demarcation between the edematous and nonedematous cornea.
Olsen and colleagues reported five cases of linear endotheliitis in 1994 and speculated that the disease was associated with HSV.
In 1991, Ohashi and colleagues concluded that the recurrence of HSV DNA in the aqueous humor of a patient indicated that idiopathic corneal endotheliopathy may have a viral origin.
Oxley and Carrim suggest in their study that a refined definition is needed for MPLE. It should be described as a form of endotheliitis “causing acute onset of blurry vision associated with multiple parallel lines of keratic precipitates, with or without corneal edema, in the absence of significant inflammation or elevation of IOP,” they said.
MPLE is a rare and possibly underdiagnosed form of endotheliitis. Larger studies are needed to investigate its etiology and factors that influence the expression pattern of keratic precipitates in herpetic corneal disease, according to Oxley and Carrim.
“We are limited by the fact that it is a rare entity,” Carrim said. “We are constantly on the lookout for new cases. If we see more patients, we will definitely pursue evidence of a herpetic origin.” – by Cheryl DiPietro
References:
- Hori Y, Maeda N, Kosaki R, Inoue T, Tano Y. Three cases of idiopathic “multiple-parallel-line” endotheliitis. Cornea. 2008;8(1):103-106.
- Ohashi Y, Yamamoto S, Nishida K, et al. Demonstration of herpes simplex virus DNA in idiopathic corneal endotheliopathy. Am J Ophthalmol. 1991;112(4):419-423.
- Olsen TW, Hardten DR, Meiusi RS, Holland EJ. Linear endotheliitis. Am J Ophthalmol. 1994;117(4):468-474.
- Oxley LA, Carrim ZI. Multiple parallel-line endotheliitis – A form of herpes simplex keratitis? Optom Vis Sci. 2012;89(3):353-355.
- Robin JB, Steigner JB, Kaufman HE. Progressive herpetic corneal endotheliitis. Am J Ophthalmol. 1985;100:336-337.
For more information:
- Zia I. Carrim, FRCOphth, can be reached at the Department of Ophthalmology, St. James’ University Hospital NHS Trust, Beckett St., Leeds LS9 7TF, United Kingdom; zia.carrim@doctors.org.uk.