NECROTIZING STROMAL KERATITIS IN AN IMMUNOCOMPETENT PATIENT SECONDARY TO HERPES SIMPLEX VIRUS INFECTION.

Report a case of necrotizing stromal keratitis (NSK) in an immunocompetent patient secondary to herpes simplex virus (HSV) infection.

Cornea subspecialty, Príncipe de Asturias University Hospital, Alcalá de Henares, Madrid, Spain.

A 65-year-old male patient with a history of amblyopia due to keratoconus in the right eye (RE) and retinal detachment in the left eye (LE). He consulted for conjunctival erythema, pain and photophobia in the RE. The slit lamp examination identified two peripheral corneal ulcers infiltrated in the upper region, associated with adjacent neovascularization, stromal edema and a mild reaction in the anterior chamber. Antibiotic coverage was started with Ofloxacin eye drops in the sterilization phase and the lesion was cultured. Due to the poor improvement after 48 hours, the treatment was changed to Ceftazidime and Vancomycin, reinforced eye drops, on an hourly schedule, in addition to Cycloplegic eye drops. Culture testing of corneal scrapings revealed no bacterial infection. After 48 hours, the symptoms worsened, the extension of the ulcer increased, marked corneal thinning, dense leukocytic stromal infiltration, and necrosis in the central region of the ulcer, so a polymerase chain reaction (PCR) was performed due to suspicion of necrotizing stromal keratitis.

The PCR was positive for herpes simplex virus 1 (HSV-1), reinforced antibiotic eye drops were suspended, the administration of Ganciclovir gel 5 times per day, Valacyclovir 1 gram 3 times a day orally, Prednisolone 1 drop 4 times per day and its subsequent gradual decrease and Moxifloxacin 1 drop 4 times per day was started. The ulcer resolved after six weeks of treatment. The patient is currently asymptomatic, with a leukoma and mild corneal thinning in the area of the lesion and BCVA similar to that prior to the episode.

Herpes simplex viral (HSV) keratitis is a common viral infection of the cornea. Stromal HSV infection has infective and immune components and is often a recurrent and potentially blinding corneal disease, especially necrotizing stromal HSV keratitis.

Necrotizing keratitis is characterized by distorted corneal architecture, substantial stromal inflammatory infiltration, and thinning. 

Stromal infection can mimic bacterial and fungal keratitis, making treatment difficult and delayed. 

The suspected diagnosis of herpetic necrotizing keratitis is important, due to the risk of corneal perforation if treatment isn’t started.