HSV-1-induced acute retinal necrosis syndrome presenting with severe inflammatory orbitopathy, proptosis, and optic nerve involvement

Objective: To present a unique case in which orbital inflammation, proptosi s, and optic neuritis were the initial symptoms of acute retinal necrosis ( ARN), The clinical presentation of ARN, as well as the currently recommende d diagnostic procedures and guidelines for medical treatment of ARN, are su mmarized. Design: Interventional case report. Testing: Polymerase chain reaction (PCR) techniques were made on the vitreo us for cytomegalovirus, Epstein-Barr virus, herpes simplex virus (HSV), var icella tester virus, and toxoplasmosis, A full laboratory evaluation was ma de together with HLA-typing and serologic tests measuring convalescent tite rs for HSV and other micro-organisms. Magnetic resonance imaging scan, comp uted tomography (CT) scan, and fluorescein angiographic examination were pe rformed. The patient was treated with acyclovir and oral prednisone. Main Outcome Measures: The patient was evaluated for initial and final visu al acuity and for degree of proptosis, periocular edema, and vitreitis. Results: The first symptoms and signs of ARN were eye pain, headache, propt osis, and a swollen optic nerve on CT scan, Other than increased C-reactive protein, all blood samples were normal. PCR was positive for HSV-type I in two separate vitreous biopsies. The patient had the strongly ARN-related s pecificity HLA-DQ7. Conclusions: This is the first report of HSV-induced ARN presenting with in flammatory orbitopathy and optic neuritis, Polymerase chain reaction for HS V-1 was positive more than 4 weeks after debut of symptoms, which is a new finding. The combination of severe vitreitis and retinal whitening, with or without proptosis, should alert the clinician to the possibility of herpes infection and treatment with intravenous acyclovir started promptly. (C) 2 000 by the American Academy of Ophthalmology.