Herpes simplex uveitis

Brief introduction of herpes simplex uveitis Herpes simplex virus (HSV) can cause uveitis by invading or by inducing an immune response after invading the body. Clinically, it can be expressed as anterior uveitis, or it can be expressed as posterior uveitis. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific people Mode of infection: non-infectious Complications: corneal disease

Causes of herpes simplex uveitis

Acquired infection (30%):

Infants also have HSV-I infection because they are exposed to HSV-I infection. The clinical and ocular manifestations of these two HSV types are basically the same. HSV-I virus is often present in normal human body, and the body's resistance is reduced. Caused by the disease, many of its predisposing factors such as colds, various fevers, gastrointestinal disorders, etc. can cause uveitis, the pathogenesis of which can be direct infection of the virus by the virus, which can be isolated from the patient's aqueous humor; May be a hypersensitivity reaction to the virus.

Virus (20%):

The anterior uveitis caused by herpes simplex virus is mainly caused by the direct invasion of the virus or the immune response caused by the virus, but the exact mechanism of retinitis caused by it is not completely clear. Experiments have shown that the virus reaches at least the path of the retina. There are three, that is, blood-derived, spreading from the anterior segment of the eye and from the central nervous system. It is generally considered that blood-borne to the retina is unlikely. Some people injected the virus into the vein of the animal, and no eye infection was found. The spread of the anterior segment does not seem to be the main route into the retina, because it is unlikely that herpes simplex retinitis will occur in patients with herpes simplex anterior uveitis. Herpes simplex retinitis is associated with it. Anterior chamber inflammation may be caused by simultaneous infection of the anterior and posterior segments of the eye, or it may be the result of "overflow" of inflammation of the retina. The third way is that the virus reaches the retina from the central nervous system, which may be caused by herpes simplex retinitis. The main route, many studies have proved that herpes simplex virus is particularly preferred for the nervous system.

Congenital infection (30%):

According to most reports, 70% of neonatal HSV infections are caused by intrauterine HSV-II type, due to the mother's herpes zoster, which is caused by exposure to infectious secretions during production.

Herpes simplex uvitis prevention

After a patient with herpes simplex virus infection in a child care institution, it should be treated at home for isolation treatment. After treatment, the patient can return. The pregnant woman with genital herpes should be delivered by cesarean section.

Herpes simplex uveitis complications Complications keratopathy

It can cause trabeculitis, which is characterized by elevated intraocular pressure and corneal edema. This increase in intraocular pressure is transient, but it can also cause damage to the optic nerve.

Herpes simplex uveal inflammation symptoms common symptoms hepatosplenomegaly keratitis herpes fever lymph node swelling fatigue uveitis

Congenital infection

(1) systemic manifestations: typical skin findings include erythema, which quickly develop into clusters of blisters, which later appear as erythema and golden yellow sputum on it. This change can be seen in the eyelids, around the mouth and in the body, often with encephalitis. It is a fetus and birth of HSV infection, often showing acute fever, lethargy and seizures. Viviparous encephalitis can cause congenital malformations, such as calcification in small brains, and can cause other diseases such as esophagitis, pharyngitis, rhinitis, pneumonia, hepatitis. , hepatosplenomegaly, glomerulonephritis, lymphadenitis, enteritis and so on.

(2) Outer eye performance: Newborn HSV-II infections often occur 2 to 14 days after birth, 1/6 neonates develop eye disease, and a few cases only have eye invasion. The most common eye disease is conjunctivitis. , followed by keratitis, manifested as diffuse corneal epithelial fluorescein staining, but also large epithelial defects, such as map-like ulcers or typical dendritic ulcers.

(3) Uveitis: more manifested as retinal choroiditis or retinal choroidal scar, yellow-white punctate lesions in the macula and posterior pole, white sheath or hemorrhage around the blood vessels, vitreous inflammation and opacity; atrophic scar lesions have pigmentation on the edges Vascular tortuosity, sometimes manifested as acute necrotizing retinitis, can also occur iritis, other can have cataract, optic neuritis, optic atrophy and small eyeballs.

2. acquired infection

(1) Systemic manifestations: HSV-I infection in children and adults is the same as intra-fetal infection, and skin herpes also occurs, which invades any part of the epidermis and mucous membranes, especially at the junction of skin and mucous membranes, mostly in the mouth and lips. Around the nostrils, the external genital area can also occur. Men are mostly located in the foreskin and glans; women are mostly located in the labia and cervix. At the beginning, the skin has a burning sensation and itching, reddish, and then clusters of small rice-sized blisters appear. The blister is located in the deep layer of the epidermis and contains a transparent slurry. The microscopic examination reveals bubble-like cells and eosinophilic intranuclear inclusions. The dermis has mild cell infiltration and telangiectasia.

HSV-I infection is often accompanied by fever, lymphadenitis, esophagitis, etc., severe cases can cause nephritis, enteritis and encephalitis.

(2) external eye performance: can cause conjunctivitis, conjunctival congestion and edema, the most common is keratitis, corneal sensation decreased, mainly two types of herpetic keratitis.

1 epithelial keratitis: a bit or stellate keratitis, dendritic keratitis and map keratitis.

2 substantial keratitis: A. discoid keratitis: discoid edema in the parenchyma at the central or paracentral portion of the cornea; B. necrotizing keratitis: characterized by inflammatory cell infiltration and tissue necrosis in the corneal parenchyma Focal or diffuse, the epithelium can also collapse to form ulcers, often combined with anterior chamber empyema.

(3) Herpes zoster has the following types:

1 herpes keratitis-iriritis ciliary body inflammation: generally believed to be caused by direct spread of corneal infection or toxins and allergic reactions, can be divided into two types: light and heavy type: the most common, is a transient inflammatory reaction, often occurs in Dendritic keratitis, a little floating matter in the anterior chamber and KP, due to mild inflammation, corneal lesions are easily overlooked, iris inflammation can disappear with the improvement of corneal disease, and severe lesions occur in herpes map or discoid keratitis In the process, KP is mostly located in the posterior wall of corneal lesions. The inflammation lasts for a long time and is prone to various complications such as post-irisal adhesion and secondary glaucoma.

2 herpes iridocyclitis: is a viral infection of the uveal itself, not accompanied by keratitis, but a history of herpetic keratitis, clinical and experimental evidence that there is a virus in the uveal tissue, acute onset, pain Obviously, there are often small KP or sheep fat KP, which may be accompanied by corneal edema and posterior elastic layer wrinkles, aqueous humor turbidity, often anterior chamber hemorrhage, sometimes limited cerebral lesions of the iris, often after the iris adhesion, the limit Iris atrophy, the formation of limited leukoplakia, there are a few cases of iritis precede keratitis, recurrent herpes can also be only iridocyclitis without keratitis, serious complications are secondary glaucoma, its incidence The mechanism is that inflammation affects the trabecular meshwork. Melame has reported a pathological examination of secondary glaucoma caused by this disease, indicating that there is mononuclear trabecular inflammation, mainly lymphocytes in the trabecular space, and most of the trabecular endothelial cells are degenerated. Cytoplasmic contents and cell debris can be seen in the trabecular space; most of the trabecular bundles are swollen, the cortical bands are thickened, and many active trabecular cells are shed, occasionally in the disintegrated trabecular cytoplasm. The virus-like particles.

3 herpetic retinal choroiditis: relatively rare, but with the increase in AIDS and other immunosuppressive patients, the incidence of herpes simplex intraocular lesions, often with systemic inflammation, if there is no systemic herpes, the diagnosis is Difficult, early fundus examination revealed white sheath and/or flaming hemorrhage along the retinal vein, arterial thinning and retinal edema, sometimes flocculation, multiple retinal choroidal lesions in the peripheral and equator of the fundus, and some cases Fine vitreous opacity, RPE and choroidal atrophy after multiple lesions, yellow exudation in the macula and posterior pole, resolved by appropriate treatment, residual scars of hyperpigmentation, especially in patients with severe HSV encephalitis There are optic disc edema, optic neuritis, arteriovenous occlusion, retinal hemorrhage, and even exudative retinal detachment, optic disc edema and subsequent optic atrophy are seen in the late stage of elevated intracranial pressure with meningoencephalitis, and some patients can occur Retinal necrosis.

Eye tissue pathology showed acute and chronic inflammation, retinal pigment epithelial cells (RPE) thickened and necrotic, lymphocytes and multinucleated giant cells were seen in the choroid and sclera, intranuclear inclusion bodies were occasionally seen in retinal cells, and electron microscopy showed that the virus particles were in the nucleus. Within the debris, there are cytoplasmic vacuoles of macrophages in the optic nerve and retina.

Herpes simplex uveitis check

1. Serum antibody detection: it has certain value in determining the infection of primary herpes simplex virus, and also helps to distinguish it from other virus infections, but it is of little value in the diagnosis of recurrent diseases, because only Serum anti-herpes simplex antibody titers increased in 5% of patients.

2. Tissue culture: may be the best way to determine herpes simplex virus infection. Herpes simplex virus can be characterized by various cytopathological changes in various cell cultures. Many virus-infected specimens can be used with monoclonal antibodies after 48-96 hours of inoculation. Immunofluorescence technique to determine whether there is herpes simplex virus infection, and to determine the type of virus infection, retinal biopsy specimens obtained at the edge of retinitis progression are more likely to obtain positive culture results, unexplained retina for progressive bilateral threatening visual acuity Inflammation should be performed on retinal choroid biopsy. The obtained specimens can be used not only for virus culture, but also for direct observation of viral particles under electron microscope. Immunohistochemistry can be used to detect viral antigens, aqueous humor, vitreous, subretinal fluid, serum and cerebrospinal fluid. Viral culture may help to determine the diagnosis of herpes simplex retinitis, but the sensitivity of these cultures is unclear.

3. Molecular biology technology: It provides a new means for the diagnosis of herpes simplex retinitis. PCR can be performed with a small amount of vitreous and aqueous humor specimens. However, when performing this examination, attention should be paid to its sensitivity. Specificity, false positives, false negatives and other issues.

The cytological features of herpes simplex retinitis are not very useful in determining the diagnosis. Ultrastructural observation has certain value in determining the diagnosis of this retinitis, but it is difficult to distinguish which virus in the herpesvirus family is caused. Therefore, the limited specimens obtained by biopsy should first be considered for tissue culture, immunohistochemical staining and PCR detection.

Diagnosis and differentiation of herpes simplex uveitis

Diagnostic criteria

1. History: Detailed inquiries about past medical history, presence or absence of herpes simplex or herpetic keratitis, and recent induction of factors such as fever history, excessive fatigue, etc.

2. Detailed examination of the eyelids, whether there are new and old herpes lesions in the cornea and whether there is lymphadenopathy before the ear.

3. Pay attention to the characteristics of herpes simplex iritis, such as iris limited lesions, anterior chamber hemorrhage, etc., and pay attention to fundus lesions.

4. Laboratory diagnosis: conditional laboratories, obtained tissue samples can be virological examination to find eosinophilic inclusion bodies or virus particles in the nucleus, immunological methods can be used to detect viral antigens, and in recent years, multiple enzyme-linked immunosorbent assays have been used. (ELISA) Detection of antibodies to HSV, VZV, CMV, EBV in serum or aqueous humor.

Differential diagnosis

1. anterior uveitis: anterior uveitis caused by herpes simplex virus should be differentiated from various diseases, mainly vesicular herpesitis caused by herpes zoster virus, uveitis caused by Epstein-Barr virus, inflammatory bowel Uveitis associated with the disease, Cogan syndrome, traumatic anterior uveitis, tuberculous anterior uveitis, syphilitic anterior uveitis.

(1) anterior uveitis caused by herpes zoster virus: anterior uveitis caused by herpes zoster virus and anterior uveitis caused by herpes simplex virus can cause keratitis, sheep fat KP, iris atrophy and intraocular pressure Elevation and other changes, easy to confuse, but herpes zoster virus caused by more herpes zoster, skin herpes zoster, occlusive vasculitis, herpes simplex virus does not cause this change (Table 1), PCR detection And specific antibody detection contributes to the differential diagnosis of both.

(2) Uveitis caused by Epstein-Barr virus: Epstein-Barr virus can cause a variety of systemic manifestations and various types of uveitis, such as fever, pharyngitis, lymphadenopathy, hepatosplenomegaly, anterior uveitis, vitreitis, and more Focal outer retinitis, chorioretinitis, uvitis, etc., specific viral capsid (VCA) IgM antibodies can exist for 2 to 6 months, VCA IgG antibodies are produced when the virus is activated, and can last a lifetime, in There is a transient increase in VCA IgA at the onset of the disease, and early-antigen-specific antibodies (IgG and IgA) peak at 3 to 4 weeks after clinical presentation and can persist for 3 to 6 months. These clinical manifestations and laboratory tests It is easy to distinguish between uveitis caused by Epstein-Barr virus and herpes simplex uveitis.

(3) trauma can cause corneal scar, infectious or non-infectious uveitis: the patient has a history of ocular penetrating injury, clinically manifested as rapid progress of infectious endophthalmitis, can also be expressed in relation to lens protein Uveitis can also be manifested as a simple traumatic anterior uveal inflammatory response or sympathetic ophthalmia, according to the history and typical clinical manifestations, it is generally not difficult to distinguish from herpes simplex uveitis.

(4) leprosy: can cause superficial avascular keratitis, stromal keratitis and uveitis with deep neovascularization, nodular leprosy is more likely to cause uveitis, patients can appear cream "iris pearl ", diameter 0.5 ~ 2.0mm, and iris atrophy, without other signs of inflammation, the patient's medical history, systemic performance and whether it comes from leprosy areas, etc. to help differential diagnosis.

(5) syphilis: easy to cause keratitis and uveitis, acquired syphilis mainly causes unilateral stromal keratitis, while congenital syphilis mainly causes bilateral stromal keratitis, uveitis is particularly prone to stage II syphilis, Unilateral or bilateral involvement, may be associated with non-specific manifestations of stage II syphilis, such as fever, discomfort, headache, sore throat, joint pain, lymphadenopathy, etc., characteristic painless maculopapular rash, appearing in the trunk and limbs It can also affect the palms and soles of the feet. Uveitis can be manifested in many types, such as anterior uveitis, chorioretinitis, vitreitis, anterior chamber empyema, exudative retinal detachment, and fan-shaped iris atrophy.

(6) Onchocerciasis: a common disease in some parts of Africa, also known as river blindness, which mainly causes sclerosing diffuse keratitis and mild chronic iridocyclitis, which can also cause choroid Retinitis, this type of uveitis has not been seen in China.

2. Posterior uveitis: herpes simplex virus after uveitis and varicella-zoster virus, cytomegalovirus, EB virus, rubella virus, measles virus, human T lymphocyte virus type I, tuberculosis, syphilis, bow Posterior uveitis caused by insects, Behcet's disease uveitis, sarcoma-like uveitis and other differentiation.

3. Primary angle-closure glaucoma: Herpes simplex keratitis often causes elevated intraocular pressure, especially when the intraocular pressure is elevated, it is easily misdiagnosed as primary glaucoma. Herpes simplex virus is often caused by corneal sensation, central corneal distribution or diffuse distribution of KP, anterior chamber glint, anterior chamber inflammatory cells, prone to iris atrophy; and acute angle-closure glaucoma often have corneal epithelial edema, The cornea is cloudy and turbid, the anterior chamber is shallow, the pupil is oval-shaped, the intraocular pressure is increased significantly, and the cup/disk ratio is increased at the fundus.

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