PERIPHERAL ULCERATIVE KERATITIS ASSOCIATED WITH MULTIPLE POSSIBLE INFECTIOUS ETIOLOGIES

To discuss the occurrence and management of peripheral ulcerative keratitis associated with multiple possible infectious etiologies.

We report the case of a 40-year-old man from Senegal who presented with severe pain, redness, and photophobia in his left eye since last three months. His local practitioner had prescribed him a topical antibiotic ointment but saw no improvement. Slit-lamp biomicroscopy revealed an area of stromal thinning at the limbus associated with neovascularization and epithelial defect. Fundus examination was normal and intraocular pressure was 12 mmHg. He was diagnosed with peripheral ulcerative keratitis and topical treatment was introduced (moxifloxacin q8h and artificial tears drops).

He denied any autoimmune disease, but referred history of vegetal trauma months ago. Corneal scrapings were collected for polymerase chain reaction (PCR) and culture testing. The patient underwent complete laboratory examination and systemic evaluation, as well as chest radiograph and interferon-gamma release assay (IGRA).

Microbial cultures were negative, but PCR detected varicella-zoster virus DNA in the corneal stroma. The rapid plasma reagin and the fluorescent treponemal antibody absorption tests were positive. Moreover, the IGRA test for tuberculosis infection was also positive, although the chest X-ray was negative for pulmonary tuberculosis. Evaluation for autoimmune etiology showed negative results. The patient was treated with oral valacyclovir 1000 mg three times daily, intramuscular penicillin G benzathine, and antituberculous therapy (isoniazid, rifampin, pyrazinamide, plus ethambutol). Despite the systemic treatment, there was no improvement, the ocular pain got worse, and the ulceration progressed circumferentially with high risk of corneal perforation. Finally, he was managed with the use of systemic and topical corticosteroids, as well as excising the limbal conjunctiva adjacent to the ulcer. The response to the treatment was good and the ulcer began to heal. The patient was followed up regularly and topical 0.05% cyclosporine A was used as a maintenance drug to prevent recurrence.

Peripheral ulcerative keratitis associated with infectious etiology is rare, but in confirmed cases we must initiate specific antimicrobial treatment. However, as it is an immune-mediated phenomenon, it may be necessary to use immunomodulators to control the inflammatory process.