Herpes zoster stromal keratitis treatment 2014,herpes cure lamisil once,alternative medicine hospitals in india ranking,kerala ayurvedic treatment in seremban - PDF Books

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Oka strain of VZV.10,11 Immunization begins in childhood and booster injections are needed.
A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Herpes zoster ophthalmicus in patients at risk for the acquired immune deficiency syndrome (AIDS). Natural history of herpes zoster ophthalmicus: predictors of postherpetic neuralgia and ocular involvement. Varicella zoster virus retrobulbar optic neuritis preceding retinitis in patients with acquired immune deficiency syndrome. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Comparison of the efficacy and safety of valaciclovir and acyclovir for the treatment of herpes zoster ophthalmicus. Chief Complaint: Red left eye for the past two months with recent onset of vertigo and otalgia. History of Present Illness: 42-year-old Caucasian female complains of an annoying red left eye for the past two months. Despite a course of antibiotics to treat a suspected sinusitis, her symptoms persisted and gradually worsened with time. Medical History: History of hypothyroidism, Type II diabetes mellitus, nonalcoholic steatohepatitis, polycystic ovarian sydrome, uterine fibroids, fibromyalgia, Celiac's disease, and borderline hypertension. Medications: Trazodone, lorazepam, meperidine, levothyroxine, albuterol, fluoxetine, montelukast, and cyclobenzaprine. Slit lamp examination: Limbal edema and stromal opacity were noted (Figure 1) as well as several fine vascular loops extending into the mid-stroma of the cornea (Figure 2). Figure 2: The iris detail is obscured in the periphery by mid-stromal opacity and edema (white arrow).
Interstitial keratitis presents a very interesting differential diagnosis: unusual infections such as syphilis, tuberculosis, mumps, Lyme disease, Chlamydia, leprosy, brucellosis, Epstein-Barr virus, Rubeola, parasitic infection, or herpes zoster and simplex have all been implicated (Witcup and Smith in Cornea, 2005).
Slit lamp examination, careful history, and appropriate serological testing help to determine the cause of interstitial keratitis, directing appropriate treatment according to the etiology. The classic finding is interstitial keratitis, which causes redness, photophobia, pain, and blurred vision.
Treatment: Anterior eye disease in Cogan's syndrome (including interstitial keratitis) is usually treated with topical corticosteroids with or without mydriatics for comfort. In the differential diagnosis of hearing loss and reduced vision especially in a young female patient one should also be thinking of Susac's syndrome. Because the nasociliary branch innervates the globe, the most serious ocular involvement develops if this branch is affected. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
In the past month she also developed vertigo, nausea, otalgia, diminished appetite, as well as progressively worsening vision.
Additionally, the patient periodically takes a daily multivitamin, fish oil, acetaminophen, and calcium and magnesium supplements.. There is mild vascular injection, especially inferiorly and at the episclera covered by the lower lid (not visualized in this Figure), associated with tenderness of the globe. Interstitial keratitis is an uncommon chronic, non-ulcerative inflammation of the corneal stroma that may be seen in isolation or may be associated with uveitis or episcleritis, as was the case with this patient.
The addition of otalgia and vertigo in the review of systems for this patient make the likely diagnosis of Cogan's syndrome.
Laboratory studies showed leukocytosis in the upper limits of normal, mildly elevated erythrocyte sedimentation rate, and non-reactive syphilis serologies. Even though interstitial keratitis is a hallmark finding, it is not essential for diagnosis.
Topical or oral NSAIDs may help in the management of associated episcleritis and scleritis. Most patients with herpes zoster ophthalmicus present with a periorbital vesicular rash distributed according to the affected dermatome. Classically, involvement of the tip of the nose (Hutchinson's sign) has been thought to be a clinical predictor of ocular involvement.


This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Additional evaluation and laboratory testing ruled out other less likely causes of interstitial keratitis in this patient and confirmed the diagnosis.
Since the original description, chronic interstitial keratitis and vestibuloauditory dysfunction remain the hallmarks of Cogan’s syndrome. Inflammation may involve other areas of the eye and result in conjunctivitis, episcleritis, scleritis, or retinal vasculitis. This condition is quite common in case of children and they may also take place in form of chromosomal disorder dsown syndrome.
A minority of patients may also develop conjunctivitis, keratitis, uveitis, and ocular cranial-nerve palsies. Treatment includes topical capsaicin cream, over-the-counter analgesics, tricyclic antidepressants, and anticonvulsants.18Cranial nerve palsies involving the third (most common), fourth, and sixth nerves may occur rarely (Figure 5). She denied any hearing loss, diplopia, fever, cough, rhinorrhea, otorrhea, tinnitus, and vomiting. In the ensuing week after our examination she developed tinnitus, though complete otolaryngology and audiology evaluation showed no hearing loss. The etiology is unknown, but is believed to involve autoimmunity to the inner ear and cornea. These are usually termed as the focal areas of stromal hyperplasia as they are being normally surrounded by hypoplasia.
Permanent sequelae of ophthalmic zoster infection may include chronic ocular inflammation, loss of vision, and debilitating pain. She presented to the University of Iowa in the spring of 2007 after having been seen by several doctors and frustrated with her persisting and progressive symptoms.
HLA-B17, HLA-A9, HLA-Bw35, and HLA-Cw4 have been correlated with an increased incidence of Cogan’s syndrome. Autoimmune inner ear disease in Cogan’s syndrome produces vertigo, nausea, ataxia, vomiting, tinnitus, and hearing loss. Audiometry should be obtained at baseline and may be used to determine the degree of hearing loss. The condition of Brushfield spots is more common with people who usually have lightly pigmented irises. Antiviral medications such as acyclovir, valacyclovir, and famciclovir remain the mainstay of therapy and are most effective in preventing ocular involvement when begun within 72 hours after the onset of the rash. Optic neuritis has been noted in about one in 400 cases and may precede retinal disease or follow acute herpes zoster ophthalmicus infection (Figure 6).17,19,20The rightsholder did not grant rights to reproduce this item in electronic media. Oral acyclovir may be beneficial as an adjunct to topical antivirals and topical steroids in severe cases of zoster keratouveitis. At follow up in our clinic one week after presentation, the interstitial keratitis and discomfort from episcleritis had totally resolved. Cogan’s syndrome is a clinical diagnosis based on the clinical findings and exclusion of infectious causes.
Timely diagnosis and management of herpes zoster ophthalmicus, with referral to an ophthalmologist when ophthalmic involvement is present, are critical in limiting visual morbidity. She will be followed closely by the otolaryngology team and oral therapy such as NSAISs or corticosteroids will be initiated if any hearing loss or worsening symptoms develop. Consequently, prompt referral to otolaryngology is essential as bilateral sensorineural hearing loss may result if treatment is delayed (Chynn and Jakobiec, 1996).
Steroid sparing therapy should be considered in patients where excessive amounts of steroids are required to prevent hearing loss or if significant steroid-related side effects result. Rheumatologic evaluation is necessary for evidence of systemic vasculitis, which is present in many affected patients (Cheson et al, 1976). In these situations, cyclophosphamide, methotrexate, azathioprine, and tacrolimus have been successfully utilized.
It is a member of the same family (Herpesviridae) as herpes simplex virus, Epstein-Barr virus, and cytomegalovirus.
Patients may develop blepharitis and present with ptosis secondary to edema and inflammation. Some systemic associations may include life-threatening aortitis (up to 10%), inflammatory bowel disease, pericarditis, abdominal pain, fatigue, weight loss, arthralgia, myalgia, fever, headache, and urticaria.


Acute vestibular dysfunction may be treated with antihistamines or benzodiazepines and bed rest. Reactivation of the latent virus in neurosensory ganglia produces the characteristic manifestations of herpes zoster, commonly known as shingles.
A vast majority of patients will have vesicular lesions on the eyelids that resolve with minimal scarring.Conjunctivitis is one of the most common complications of herpes zoster ophthalmicus. Normal aging, poor nutrition, and immunocompromised status correlate with outbreaks of herpes zoster, and certain factors such as physical or emotional stress and fatigue may precipitate an episode.Herpes zoster ophthalmicus occurs when reactivation of the latent virus in the trigeminal ganglia involves the ophthalmic division of the nerve. The conjunctiva appears injected and edematous, often with petechial hemorrhages.9 The findings usually resolve within one week. Direct ocular involvement is not specifically correlated with age, gender, or severity of disease.
The clinical features of corneal disease include direct viral infection, antigen-antibody reactions, delayed cell-mediated hypersensitivity reactions, and neurotrophic damage.7 Patients with corneal disease present with varying degrees of decreased vision, pain, and light sensitivity.
Corneal complications occur in approximately 65 percent of cases of herpes zoster ophthalmicus.7Epithelial Keratitis.
The earliest corneal finding is punctate epithelial keratitis.10 On slit lamp examination, this appears as multiple, focal, swollen lesions that stain with rose bengal or fluorescein dye. These lesions probably contain live virus and may either resolve or progress to dendrite formation.
Punctate epithelial keratitis may present as early as one or two days after the initial skin rash, while dendrites often present at four to six days but can appear many weeks later.11Herpes zoster virus dendrites appear as elevated plaques and consist of swollen epithelial cells.
Dendrites also stain with rose bengal and fluorescein dye ( Figure 2, part b) and can be viewed by Wood's lamp or slit lamp examination. The earliest finding of corneal stromal involvement presents during the second week of disease, occurring in 25 to 30 percent of patients with herpes zoster ophthalmicus.13 The condition, known as anterior stromal keratitis or nummular keratitis, is characterized by multiple fine granular infiltrates in the anterior corneal stroma below the epithelial layer (Figure 3).
Most of the infiltrates lie directly beneath pre-existing dendrites or areas of punctate epithelial keratitis. This later stage of stromal keratitis is relatively uncommon and typically develops three to four months after the initial acute episode, but development can range from one month to many years later.7 It is usually central and preceded by anterior stromal keratitis. The keratitis may present as a lesion consisting of a localized area of inflammation affecting all levels of the stroma, or as peripheral infiltrates that may have a surrounding immune ring. Corneal edema may be a prominent feature at this stage, usually with associated anterior chamber inflammation. A chronic relapsing course is not unusual, especially without timely and adequate treatment.
Corneal neovascularization and lipid infiltrates may occur in patients with uncontrolled chronic disease. The pathogenesis of stromal disease probably involves a delayed cell-mediated hypersensitivity reaction.Neurotrophic Keratopathy. Neurotrophic keratitis is the end result of decreased corneal sensation from herpes zoster virus-mediated destruction, including susceptibility to mechanical trauma, decreased lacrimation, and delayed epithelial healing.7 Corneal thinning is a serious complication that may lead to corneal perforation. Using preservative-free lubricating drops and ointment can prevent the development of epithelial defects.UVEITISAnterior uveitis, which is diagnosed by slit lamp examination, refers to inflammation of the iris and ciliary body and occurs frequently with herpes zoster ophthalmicus.
The inflammation is generally mild and transient, but it frequently causes a mild elevation in intraocular pressure. As with stromal keratitis, the course of disease may be prolonged, especially without timely, adequate treatment. Chronic inflammation can lead to endothelial cell injury, resulting in corneal edema.EPISCLERITIS AND SCLERITISFindings of episcleritis include localized or diffuse redness, as well as pain and swelling of the conjunctiva and episclera. Both conditions may be accompanied by localized stromal keratitis.ACUTE RETINAL NECROSIS AND PROGRESSIVE OUTER RETINAL NECROSIS SYNDROMESHerpes zoster virus is considered the offending agent in most cases of acute retinal necrosis and progressive outer retinal necrosis syndromes. Acute retinal necrosis is characterized by peripheral patches of retinal necrosis that rapidly coalesce (Figure 4), occlusive vasculitis, and vitreous inflammation.
Conversely, immunocompromised patients with progressive outer retinal necrosis are unable to mount a vitreous inflammatory response, leading to rapid involvement of the macula.



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