Bilateral Epithelial Herpetic Keratitis After Treatment With Adalimumab: A Case Report

To describe a case of bilateral epithelial herpetic keratitis in a patient with a history of unilateral herpetic keratitis, triggered after initiating adalimumab to treat psoriasis.

The emergency department and cornea clinic at our institution.

A 68-year-old male with a history of epithelial herpetic keratitis in the right eye presented to the emergency department with hyperemia, photophobia, tearing, and morning discharge in both eyes  1 month after starting adalimumab for a severe acute psoriasis flare that required hospitalization. Anterior segment examination revealed dendritic epithelial lesions on the corneas of both eyes, compatible with bilateral epithelial herpetic keratitis. Treatment was initiated with oral valacyclovir and topical ganciclovir gel, leading to the resolution of corneal lesions within 10 days. Adalimumab was not discontinued, and long-term prophylactic treatment with oral valacyclovir at 500 mg daily was decided and continues to date.

Reactivation of latent infections, such as herpes simplex virus, with potential atypical presentation, is a known adverse effect of TNFα antagonists described in the literature. These drugs predominantly interfere with cellular immunity. We are seeing a growing presence of these medications in clinical practice, with limited experience regarding potential ocular adverse effects. This case involves the reactivation of bilateral herpetic keratitis following the initiation of adalimumab. Bilateral involvement is rare in herpetic keratitis. We emphasize the importance of vigilance in patients with a history of herpes simplex infection when initiating TNFα antagonists.

This case describes adalimumab as a potential cause of bilateral epithelial herpetic keratitis. In ophthalmological consultations, it is essential to pay close attention to patients with a history of herpetic infections starting therapy with TNFα antagonists.