Ophthalmic Manifestations In Mpox Virus Infection: Is The Cornea A Reservoir For Viral Latency?

There are no known sites of latent infection by mpox virus, and most cases described in the literature appear to involve reinfections rather than recurrences. Conversely, in ophthalmology, herpes simplex virus type 1 (HSV-1) remains latent in the trigeminal ganglia and can be reactivated by various factors, including stress, thermal stimulation, or immunosuppression. Several studies have indicated the potential for latent HSV-1 infection in the human cornea through virological and molecular techniques. Our objective is to present a case of recurrent uveitis due to mpox, accompanied by molecular evidence, to support the possibility of viral corneal latency.

Mpox virus infection is a significant public health concern worldwide given its potential for severe manifestations and the propensity for outbreaks. A global case series published January 2024 reports 37 cases of mpox systemic reinfection worldwide.

However, according to the current literature, there are no cases of mpox virus ophthalmic reinfection or recurrence.

PCR was used to demonstrate the presence of mpox virus DNA in the cornea of a 35-year-old immunocompetent patient during multiple episodes of anterior uveitis and keratitis. OCT-SA was conducted during periods of remission. Sequential imaging was performed during several visits to monitor alterations in the cornea.

The patient first exhibited minimal skin lesions and a corneal erosion in the left eye in September 2022, prompting the initiation of treatment. Subsequently, in January and April 2023, the patient developed a geographic corneal ulcer with infiltration accompanied by uveitis. Recurrences occurred in May, June 2023, and February 2024, manifesting as uveitis characterized by pigmented retrokeratic precipitates and endotheliitis.

PCR testing yielded positive results during episodes of keratitis. However, the results were negative during episodes of uveitis with minimal corneal erosions. Additionally, PCR revealed no detectable virus during remission periods.

In December 2022, Optical coherence tomography revealed a diffuse haze-type scar, measuring 300 microns in depth within the anterior segment. In December 2023, a reduction in corneal opacities was noted compared to previous images, with corneal leukomas measuring 200 microns at the deepest point.

Mpox virus infections with ophthalmic manifestations are infrequent, which consequently pose challenges in both diagnosis and management. Severe ocular manifestations, such as anterior uveitis accompanied by ocular hypertension, may occur in immunocompetent individuals without underlying medical conditions, even in the absence of significant systemic symptoms. Understanding mpox disease progression and the potential for corneal latency could significantly enhance treatment strategies. The presented findings, coupled with current evidence concerning HSV-1, strongly support the possibility of corneal viral latency. However, detection techniques should be performed in aqueous humor to confirm the etiology of mpox virus-induced uveitis.