Bilateral Herpetic Keratitis in a Patient with Pemphigus Foliaceus

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Bilateral Herpetic Keratitis in a Patient with
Pemphigus Foliaceus
2007 ASCRSPoster No. 200
Hee Kyung Yang, MD, Young Keun Han, MD, Won Ryang
Wee, MD, Jin Hak Lee, MD, Ji Won Kwon, MD
Department of Ophthalmology Seoul National
University College of Medicine Seoul National
University Hospital, Korea
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Financial Disclosure

• None of the authors has a financial
• interest in any material or method in
• the study.

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Background

• Ocular involvement in pemphigoid disease are
  often reported.
• A majority of these lesions are confined to the
  conjunctiva such as pseudomembranous
  conjunctivitis, but the cornea is seldom
  involved.
• Herpes simplex virus infection occurs during the
  course of pemphigus, but herpetic keratitis has
  been reported in only a few cases of pemphigus
  vulgaris and bullous pemphigoid.
• Herpetic keratitis associated with pemphigus
  foliaceus has not yet been reported.

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Purpose

• To report a case of Asymmetric Bilateral Herpetic
  Keratitis, which occured after rapid oral
  Corticosteroid tapering in a patient of Pemphigus
  Foliaceus.

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Case (M / 71 Yr)

• 6MA Diagnosed with Pemphigus Foliaceus
• On Long-term Immunosuppressive therapy
• Oral Prednisolone (Pd) 20 mg tid
• Oral Azathioprine (AZA) 50 mg tid
• 2WA Skin lesions had improved
• Oral Prednisolone was tapered to 40 mg qd
• 1WA B) Eye Pain, Epiphora developed
• A week after starting rapid corticosteroid
  tapering from 60mg qd ? 40mg qd
• No other history of previous ocular disease

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Primary visit
A week after starting rapid corticosteroid
tapering

• The right eye with geographic epithelial
  defects.
• The left eye showing geographic epithelial
  defects.

VOD 20/25 VOS 20/50
Dx Bilateral herpetic keratitis Mx B) Topical
3 Acyclovir (Herpecid oint, Samil) ointment
5/d Prednisolone 30mg qd (slow tapering)
Cyclosporine A (CsA) 100mg bid (replacement of
AZA)
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1 Wk
A week after topical antiviral treatment

• (A) The right eye with healed epithelial defects.
• (B) Fluorescein-stained image of the left eye.
  Epithelial defects have increased even with
  topical antiviral treatment. Hypopyon is
  detected.

VOD 20/25 VOS HM
Mx Oral Famciclovir 400mg 5/d B) Fortified 10
Cefazolin q2hrs 2 Gentamycin eye drops
q2hrs B) Topical 3 Acyclovir (Herpecid oint,
Samil) ointment R) 2/d L) 5/d Prednisolone 25mg
qd (slow tapering)
8
4 Wk
3 weeks of systemic and topical antiviral
treatment L) Persistent epithelial defects
?Amniotic membrane TPL

• Amniotic membrane transplantation on the left
  eye.
• - Fresh frozen amniotic membrane (Bioland)
• - On-lay technique

Mx Oral Famciclovir 400mg tid tapering L) 0.5
Levofloxacin (Cravit , Santen Phamaceutical
CO.,LTD) qid B) Topical 3 Acyclovir (Herpecid
oint, Samil) ointment 2/d L) Autoserum q2hrs
Prednisolone 20mg qd (slow tapering)
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8 Wk
Amniotic membrane was removed after 3 weeks

• (A) The epithelial defects have totally healed of
  the left eye. A small portion of subepithelial
  opacity is left.

VOS 20/25
Mx Oral Famciclovir 400mg bid tapering L)
0.5 Levofloxacin (Cravit , Santen Phamaceutical
CO.,LTD) qid B) Topical 3 Acyclovir (Herpecid
oint, Samil) ointment 2/d Prednisolone 15mg qd
(slow tapering)
10
1 yr FU

• During the period of corticosteroid tapering,
  there was no sign of recurrent infection in both
  eyes.
• Best corrected visual acuities were maintained
  during the whole period.
• VOD 20/25 VOS 20/25
• There was no sign of exacerbation of any skin
  lesions throughout.

Mx B) Topical 3 Acyclovir (Herpecid oint,
Samil) ointment qd B) 0.5 Carboxymethylcellulose
(Refresh plus, Allergan, U.S.A.) q2hrs
Prednisolone 10mg qod (slow tapering) CsA
150mg bid
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Results - Summary

• A week after starting topical antiviral
  medication, the right eye had healed, but the
  left eye showed increased stromal edema with
  enlarged epithelial defects.
• Oral acyclovir as well as topical broad spectrum
  antibiotics were applied in the left eye. Stromal
  edema cleared within a week but the epithelial
  defect was stationary.
• Amniotic membrane transplantation was performed
  on the left eye, and 3 weeks later, corneal
  epithelial defects of the left eye healed
  remarkably.

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Conclusion

• Patients with autoimmune disorder or who are on
  immunosuppression therapy have a higher chance of
  developing bilateral herpetic keratitis, and may
  show atypical features, such as asymmetry between
  fellow eyes.
• Rapid corticosteroid tapering may act as a
  triggering factor of herpes virus infection, so
  should be tapered slowly.
• Amniotic membrane transplantation seems to be an
  effective therapeutic modality for persistent
  epithelial defects as a complication of herpetic
  keratitis.