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Intraocular Long-term Persistence of Herpes Simplex Virus Type-2 in Acute Retinal Necrosis-syndrome after Antiviral-therapy

1Heger T., 1Dithmar S., 2Bugert J., 1Holz F. G.,
1Ruprecht-Karls-Universität Heidelberg, Universitäts-Augenklinik (Heidelberg)
2Hygieneinstitut, Virologie (Heidelberg)

Background: Acute retinal necrosis syndrome (ARNS) is a rare necrotizing retinitis associated with viral infections affecting generally immunocompetent patients. The herpes zoster-varicella virus (VZV), herpes simplex virus (HSV) and rarely cytomegalie virus (CMV) have been implicated as causes of the disease.
Case report: A 38-year-old man presented with a fast progressing painless visual impairment of his left eye. The examination showed a prominent inflammatory reaction in the vitreous humor and anterior chamber, evidence of occlusive vasculopathy and a circumferential retinal necrosis. Serum analysis did not reveal any acute viral infection, but IgG antibodies against VZV, CMV and HSV were detected. An antibiotic and antiviral (Valaciclovir) therapy was started and a vitrectomy with instillation of silicon oil was performed. Polymerase chain reaction (PCR) was done on the vitreous and herpes simplex virus type 2 DNA was detected. While continuing the antiviral therapy, no progression of the retinitis was observed. Because of temporary disorders in walking the patient's cerebrospinal fluid (CSF) was tested. A PCR assay was first positive for HSV type 2, however, this result could not be confirmed. Six months later cataract surgery was performed and PCR analysis of the intraocular fluid proved the presence of HSV-DNA. The status of the retina remained stable (follow up: 18 months), the right eye is not involved.
Conclusions: Apparently HSV can persist in the eye of ARNS patients despite treatment with antiviral drugs and long time after stabilization of the retinitis. The prognosis for final visual acuity is poor and in about 30 percent of the patients the second eye will be concerned within the following 10 years. An antiviral treatment should be started immediately in case of evidence of ARNS. However, a long-term treatment with antiviral agents should be avoided as a source of resistance.