A 32-year-old man arrives at the emergency department with pain, watering, and redness in his left eye for the past 5 days. He had similar symptoms in the same eye a few months ago that resolved after about a week. The patient is a construction worker and has been remodeling the attic and roof of an older home for the past few weeks. Temperature is 36.8 C (98.2 F), blood pressure is 118/78 mm Hg, heart rate is 82/min. Clear drainage is visible from the left eye, which is diffusely erythematous around the cornea. The right eye and bilateral periorbital regions are unremarkable. There are no oral lesions. Slit-lamp examination of his left eye is shown below: What is the most likely diagnosis for this patient?

Question

A 32-year-old man arrives at the emergency department with pain, watering, and redness in his left eye for the past 5 days.  He had similar symptoms in the same eye a few months ago that resolved after about a week.  The patient is a construction worker and has been remodeling the attic and roof of an older home for the past few weeks.  Temperature is 36.8 C (98.2 F), blood pressure is 118/78 mm Hg, heart rate is 82/min.  Clear drainage is visible from the left eye, which is diffusely erythematous around the cornea.  The right eye and bilateral periorbital regions are unremarkable.  There are no oral lesions.  Slit-lamp examination of his left eye is shown below:  What is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_d0fc_ae0d_bc81_03a177ab8f2e_MD0003_00 This patient with pain, watering, and redness of the eye has branching ulcerations on slit-lamp examination with fluorescein dye. These findings are consistent with herpes simplex virus (HSV) keratitis, a manifestation of viral reactivation and a frequent cause of corneal blindness. HSV keratitis occurs most commonly in adults and usually affects one eye in otherwise healthy patients. Symptoms include the acute onset of eye pain, photophobia, tearing, and blurred vision. Conjunctival erythema around the corneal border or limbus (ie, ciliary flush) is classic, as seen here. A history of prior episodes (usually affecting the same eye) may be present, and the recurrences are often provoked by excessive sun exposure (eg, outdoor occupation), fever, or immunodeficiency (eg, HIV). Diagnosis of HSV keratitis is typically made by slit-lamp examination with fluorescein dye, which classically reveals dendritic ulcers (linear branching lesions); corneal vesicles may also be present. Viral culture or PCR can confirm the diagnosis in atypical cases. Management is antiviral therapy (oral or topical); topical glucocorticoid monotherapy should be avoided if there is any suspicion of HSV keratitis due to associated risk of vision loss. Patients with frequent recurrences may warrant oral suppressive therapy. (Choice A) Bacterial keratitis usually occurs after improper contact lens use or corneal trauma. Patients typically have mucopurulent drainage (not clear watering), and the cornea appears hazy with a round, white ulceration, not branching lesions. (Choice B) Corneal abrasion presents with severe pain, photophobia, and foreign-body sensation after trauma (which did not occur in this case) and usually improves within 1-2 days. In addition, fluorescein staining may reveal a linear lesion, but the branching pattern seen in this patient is not typical. (Choice C) Fungal keratitis is rare and typically occurs after corneal injury (eg, thorn in the eye) in immunocompromised patients. In addition, presentation is gradual and progressive rather than acute, and the cornea shows multiple infiltrates with feathery edges, not dendritic branching. (Choice E) Herpes zoster ophthalmicus is an infection caused by varicella zoster virus and most commonly affects elderly individuals. Presentation includes fever, malaise, and burning/pruritus of the periorbital region. Dendritic corneal ulcers can occur, but a vesicular rash around the eye in the distribution of the cutaneous branch of the first division of the trigeminal nerve is almost always present. trigeminal nerve Educational objective: Herpes simplex keratitis presents acutely with eye pain, redness, photophobia, tearing, and blurred vision. Slit-lamp examination reveals characteristic dendritic ulcers (linear branching). References: Herpes simplex keratitis. (http://www.ncbi.nlm.nih.gov/pubmed/31424862)

A 32-Year-Old Man Arrives at the Emergency Department with Pain