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Letter Regarding: Clinical Features of Pediatric Age Herpes Simplex Virus Keratitis

Letter Regarding: Clinical Features of Pediatric Age Herpes Simplex Virus Keratitis LETTERS TO THE EDITOR 3. Tshionyi M, Shay E, Lunde E, et al. Hemangio- primary HSV infection in association with Letter Regarding: genesis and lymphangiogenesis in corneal vesicular blepharokeratoconjunctivitis, pathology. Cornea. 2012;31:74–80. Clinical Features of not in recurrent keratitis because of 4. Holbach LM, Asano N, Naumann GOH. Infection of the corneal endothelium in herpes simplex reactivation of latent HSV. Pediatric Age Herpes keratitis. Am J Ophthalmol. 1998;126:592–594. Ancillary testing is also important 5. Holland EJ, Mahanti RL, Belongia EA, et al. in making the diagnosis of HSV kerati- Simplex Virus Keratitis Ocular involvement in an outbreak of herpes tis. The authors correctly acknowledge gladiatorum. Am J Ophthalmol. 1992;114:680–684. the lack of PCR confirmation of HSV 6. Xu F, Lee FK, Morrow RA, et al. Seroprevalence of herpes simplex virus type 1 in children in the infection as a limitation of their study, To the Editor: United States. JPediatr. 2007;151:374–377. although PCR has limited diagnostic Ulman et al should be congratu- 7. Liu S, Pavan-Langston D, Colby KA. Pediatric value in cases without epithelial keratitis herpes simplex of the anterior segment: charac- lated on their publication entitled “Clini- or uveitis. HSV serum antibody testing teristics, treatment, and outcomes. Ophthalmol- cal Features of Pediatric Age Herpes ogy. 2012;119:2003–2008. is often overlooked but has a useful Simplex Virus Keratitis.” There is a negative predictive value in pediatric dearth of literature characterizing keratitis patients with recurrent HSV keratitis Reply: in children, and I commend the authors (even isolated stromal keratitis) because We are writing to address the for endeavoring to address this gap. of the relatively low seroprevalence of concerns expressed by Redd TK in his However, I suspect that a substantial HSV IgG in this age group compared letter regarding our article entitled “Clin- portion of the subjects included in this with adults. ical Features of Pediatric Age Herpes study did not truly have herpes simplex Studies characterizing recurrent Simplex Virus Keratitis” published in the virus (HSV) keratitis. The only inclusion pediatric HSV keratitis should require Cornea journal. First of all, we would like criterion was a clinical diagnosis of HSV confirmation of the presence of serum to thank Redd TK for taking the time to keratitis, and although the authors indicate HSV IgG for inclusion and PCR or read our article with interest and pro- that HSV keratitis in children is culture positivity in cases of epithelial viding valuable feedback. We truly frequently misdiagnosed as “phlyctenular keratitis and/or uveitis. Detailed exami- appreciate their participation and contri- keratoconjunctivitis,” I find the converse nation findings including the distribution butions to the scientificcommunity. to be more common, namely, that ble- of corneal neovascularization and cor- For the image presented in pharokeratoconjunctivitis of childhood neal sensitivity testing (although the Figure 1A of our article, Redd TK noted (especially rosacea keratitis) is frequently latter can be difficult to reliably obtain that the corneal findings are more consis- misdiagnosed as HSV keratitis. An excel- in children) as well as a thorough tent with rosacea keratitis than with stromal lent example of this is demonstrated in clinical history are also crucial to reli- herpetic keratitis. As Nazir et al empha- Figure 1A of this manuscript, depicting a ably differentiate this entity from other sized in their case series, ocular rosacea in child with very superficial corneal neo- major causes of pediatric keratitis. The pediatric patients is an important disease vascularization affecting the inferior cor- absence of this diagnostic information that must be kept in mind when diagnosing nea with discrete anterior stromal results in a heterogenous study popula- herpetic keratitis. Because our clinic is a infiltrates at the site of blood vessel tion composed of multiple incompletely tertiary referral center, we follow up a large termination. This image is labeled as distinguished pathologies, making it dif- number of pediatric patients with herpetic “HSV stromal keratitis,” but the appear- ficult to draw meaningful conclusions keratitis and ocular rosacea, and we occa- ance is much more characteristic of regarding the natural history and prog- sionally come across cases where we have rosacea keratitis. This diagnosis can be nosis of the disease of interest. difficulty in clinical differentiation of these challenging in children because the cor- 2 diseases. However, we rechecked the neal manifestations often occur in the records of our patient in Figure 1A and Financial disclosures/conflicts of interest: absence of the typical cutaneous manifes- confirmed that we did not encounter any tations of rosacea, but a careful examina- None reported. meibomian gland dysfunction, lid telangi- tion of the eyelids, corneal sensation ectasia, blepharitis, or skin manifestations testing, and determination of the depth Travis K. Redd, MD, MPH that couldleadtoadiagnosisofocular of corneal neovascularization can help 3 rosacea. In addition, an important detail in Casey Eye Institute, Oregon Health & differentiate rosacea keratitis from HSV clarifying the diagnosis is the patient’s Science University, Portland, OR keratitis. The latter predominantly response to treatment. Hung et al stated presents with deep stromal neovasculari- in their study that Demodex infestation, REFERENCES zation (presumably because of its peculiar which is an entity frequently seen together 1. Ulman EA, Selver OB, Biler ED, et al. Clinical with ocular rosacea, is important in the proclivity to infect the corneal endothe- features of pediatric age herpes simplex virus differential diagnosis of patients with her- lium) in association with localized relative keratitis. Cornea. 2023;42:1099–1103. 3,4 2. Donmez O, Akova YA. Pediatric ocular acne petic keratitis and that the diagnosis should hypoesthesia. HSV can also be associ- rosacea: clinical features and long term follow- be questioned if no response to antiviral ated with phlyctenular keratoconjunctivi- up of sixteen cases. Ocul Immunol Inflamm. 2021;29:57–65. treatment is obtained for more than 1 week. tis but typically only as a manifestation of Cornea Volume 42, Number 12, December 2023 www.corneajrnl.com e21 Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Cornea Wolters Kluwer Health

Letter Regarding: Clinical Features of Pediatric Age Herpes Simplex Virus Keratitis

Redd, Travis K.
Cornea , Volume 42 (12) – Dec 14, 2023
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Wolters Kluwer Health
Copyright
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
ISSN
1536-4798
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0277-3740
DOI
10.1097/ico.0000000000003327
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Abstract

LETTERS TO THE EDITOR 3. Tshionyi M, Shay E, Lunde E, et al. Hemangio- primary HSV infection in association with Letter Regarding: genesis and lymphangiogenesis in corneal vesicular blepharokeratoconjunctivitis, pathology. Cornea. 2012;31:74–80. Clinical Features of not in recurrent keratitis because of 4. Holbach LM, Asano N, Naumann GOH. Infection of the corneal endothelium in herpes simplex reactivation of latent HSV. Pediatric Age Herpes keratitis. Am J Ophthalmol. 1998;126:592–594. Ancillary testing is also important 5. Holland EJ, Mahanti RL, Belongia EA, et al. in making the diagnosis of HSV kerati- Simplex Virus Keratitis Ocular involvement in an outbreak of herpes tis. The authors correctly acknowledge gladiatorum. Am J Ophthalmol. 1992;114:680–684. the lack of PCR confirmation of HSV 6. Xu F, Lee FK, Morrow RA, et al. Seroprevalence of herpes simplex virus type 1 in children in the infection as a limitation of their study, To the Editor: United States. JPediatr. 2007;151:374–377. although PCR has limited diagnostic Ulman et al should be congratu- 7. Liu S, Pavan-Langston D, Colby KA. Pediatric value in cases without epithelial keratitis herpes simplex of the anterior segment: charac- lated on their publication entitled “Clini- or uveitis. HSV serum antibody testing teristics, treatment, and outcomes. Ophthalmol- cal Features of Pediatric Age Herpes ogy. 2012;119:2003–2008. is often overlooked but has a useful Simplex Virus Keratitis.” There is a negative predictive value in pediatric dearth of literature characterizing keratitis patients with recurrent HSV keratitis Reply: in children, and I commend the authors (even isolated stromal keratitis) because We are writing to address the for endeavoring to address this gap. of the relatively low seroprevalence of concerns expressed by Redd TK in his However, I suspect that a substantial HSV IgG in this age group compared letter regarding our article entitled “Clin- portion of the subjects included in this with adults. ical Features of Pediatric Age Herpes study did not truly have herpes simplex Studies characterizing recurrent Simplex Virus Keratitis” published in the virus (HSV) keratitis. The only inclusion pediatric HSV keratitis should require Cornea journal. First of all, we would like criterion was a clinical diagnosis of HSV confirmation of the presence of serum to thank Redd TK for taking the time to keratitis, and although the authors indicate HSV IgG for inclusion and PCR or read our article with interest and pro- that HSV keratitis in children is culture positivity in cases of epithelial viding valuable feedback. We truly frequently misdiagnosed as “phlyctenular keratitis and/or uveitis. Detailed exami- appreciate their participation and contri- keratoconjunctivitis,” I find the converse nation findings including the distribution butions to the scientificcommunity. to be more common, namely, that ble- of corneal neovascularization and cor- For the image presented in pharokeratoconjunctivitis of childhood neal sensitivity testing (although the Figure 1A of our article, Redd TK noted (especially rosacea keratitis) is frequently latter can be difficult to reliably obtain that the corneal findings are more consis- misdiagnosed as HSV keratitis. An excel- in children) as well as a thorough tent with rosacea keratitis than with stromal lent example of this is demonstrated in clinical history are also crucial to reli- herpetic keratitis. As Nazir et al empha- Figure 1A of this manuscript, depicting a ably differentiate this entity from other sized in their case series, ocular rosacea in child with very superficial corneal neo- major causes of pediatric keratitis. The pediatric patients is an important disease vascularization affecting the inferior cor- absence of this diagnostic information that must be kept in mind when diagnosing nea with discrete anterior stromal results in a heterogenous study popula- herpetic keratitis. Because our clinic is a infiltrates at the site of blood vessel tion composed of multiple incompletely tertiary referral center, we follow up a large termination. This image is labeled as distinguished pathologies, making it dif- number of pediatric patients with herpetic “HSV stromal keratitis,” but the appear- ficult to draw meaningful conclusions keratitis and ocular rosacea, and we occa- ance is much more characteristic of regarding the natural history and prog- sionally come across cases where we have rosacea keratitis. This diagnosis can be nosis of the disease of interest. difficulty in clinical differentiation of these challenging in children because the cor- 2 diseases. However, we rechecked the neal manifestations often occur in the records of our patient in Figure 1A and Financial disclosures/conflicts of interest: absence of the typical cutaneous manifes- confirmed that we did not encounter any tations of rosacea, but a careful examina- None reported. meibomian gland dysfunction, lid telangi- tion of the eyelids, corneal sensation ectasia, blepharitis, or skin manifestations testing, and determination of the depth Travis K. Redd, MD, MPH that couldleadtoadiagnosisofocular of corneal neovascularization can help 3 rosacea. In addition, an important detail in Casey Eye Institute, Oregon Health & differentiate rosacea keratitis from HSV clarifying the diagnosis is the patient’s Science University, Portland, OR keratitis. The latter predominantly response to treatment. Hung et al stated presents with deep stromal neovasculari- in their study that Demodex infestation, REFERENCES zation (presumably because of its peculiar which is an entity frequently seen together 1. Ulman EA, Selver OB, Biler ED, et al. Clinical with ocular rosacea, is important in the proclivity to infect the corneal endothe- features of pediatric age herpes simplex virus differential diagnosis of patients with her- lium) in association with localized relative keratitis. Cornea. 2023;42:1099–1103. 3,4 2. Donmez O, Akova YA. Pediatric ocular acne petic keratitis and that the diagnosis should hypoesthesia. HSV can also be associ- rosacea: clinical features and long term follow- be questioned if no response to antiviral ated with phlyctenular keratoconjunctivi- up of sixteen cases. Ocul Immunol Inflamm. 2021;29:57–65. treatment is obtained for more than 1 week. tis but typically only as a manifestation of Cornea Volume 42, Number 12, December 2023 www.corneajrnl.com e21 Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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Cornea – Wolters Kluwer Health

Published: Dec 14, 2023

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