Acute Epstein-Barr virus infection causing bilateral conjunctival hemorrhages.

Abstract: The systemic and ocular manifestations of acute Epstein-Barr virus infection are protean. Conjunctival hemorrhage has been described once. This report describes a young male who had bilateral conjunctival hemorrhages in the setting of acute Epstein-Barr virus infection.

Key Words: conjunctival hemorrhage, Epstein-Barr virus, eye

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Epstein-Barr virus (EBV) is the most common causative agent of the infectious mononucleosis syndrome, typically characterized by fever, pharyngitis, and cervical adenopathy. Diverse systemic manifestations involving various organs of the body have been described in the literature. (1) The ocular manifestations of acute EBV infection can affect almost any segment of the eye. (2,3)

Case Report

A 21-year-old male with no previous medical problems presented to the emergency room with high-grade fever and chills of 4 days' duration. He also complained of generalized fatigue and headache and noted some puffiness around the eyes. There was no sore throat, but he had a mild, dry cough. He reported a history of travel to Africa 2 weeks before the onset of symptoms. He reported no high-risk sexual exposure. On examination, his temperature was 38.6[degrees]C and he had mild conjunctival erythema and periorbital swelling. There were small erythematous papules on the extremities. The liver edge could be palpated at 2 cm below the costal margin. No splenomegaly or significant lymphadenopathy was noted. The white blood cell count was 4,600/[mm.sup.3], with 44% neutrophils and 44% lymphocytes, and the platelet count was 110,000/[mm.sup.3]. The liver enzymes were slightly elevated (aspartate aminotransferase, 110; alanine aminotransferase, 163). Blood smear inspection for malaria parasites was negative on two occasions. The next day, the patient developed conjunctival suffusion and hemorrhage in both eyes, and he had ecchymotic lesions over the eyelids (Figure). Monospot, Weil-Felix, and antibodies against leptospira, brucella, cytomegalovirus, and toxoplasma were all negative. He was started empirically on doxycycline for suspected African tick-bite fever, pending the results of specific antibodies against Rickettsia africae. Over the next few days, however, the white cell count started showing lymphocytic predominance with atypical lymphocytes seen on peripheral blood film inspection. At that time, the monospot test was repeated and turned weakly positive, and EBV immunoglobulin M was positive. Antibodies against R africae were negative. The patient was then diagnosed with acute EBV infection.

Discussion

Various ocular disease entities have been linked to EBV, including oculoglandular syndrome, (4) keratitis, (5) uveitis, (6,7) dacryoadenitis, (8) and conjunctivitis. (4,5,9-11) There is only one report in the literature describing conjunctival hemorrhage caused by EBV. (7) The patient was a 58-year-old male who presented with bilateral visual loss, pain, and redness and was found on examination to have hemorrhagic conjunctivitis and uveitis. Polymerase chain reaction amplification on the aqueous humor was positive for EBV DNA and negative for other herpes viruses. Of note, no fever, rash, or sore throat was present in this case.

Our patient did not have the classic symptoms and signs of infectious mononucleosis initially, and the monospot test was negative on presentation, but he had evidence of a systemic infection. The subsequent appearance of atypical lymphocytes prompted us to revisit the diagnosis of acute EBV infection, especially in the absence of an alternate diagnosis.

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Conclusion

Our case underscores the protean systemic and ocular manifestations of EBV infection, and suggests that EBV should be added to the differential diagnosis in patients with fever and conjunctival hemorrhage, even in the absence of symptoms of infectious mononucleosis.

Copy from one, it's plagiarism; copy from two, it's research.
--Wilson Mizner

Accepted April 7, 2004.

References

1. Straus SE, Cohen JI, Tosato G, et al. Epstein-Barr virus infections: biology, pathogenesis, and management. Ann Intern Med 1993;118:45-58.

2. Matoba AY, Ocular disease associated with Epstein-Barr virus infection. Surv Ophthalmol 1990;35:145-150.

3. Pflugfelder SC, Crouse CA, Atherton SS. Ophthalmic manifestations of Epstein-Barr virus infection. Int Ophthalmol Clin 1993;33:95-101.

4. Meisler DM, Bosworth DE, Krachmer JH. Ocular infectious mononucleosis manifested as Parinaud's oculoglandular syndrome: Am J Ophthalmol 1981;92:722-726.

5. Matoba AY, Wilhelmus KR, Jones DB. Epstein-Barr viral stromal keratitis. Ophthalmology 1986;93:746-751.

6. Usui M, Sakai J. Three cases of EB virus-associated uveitis: Int Ophthalmol 1990;14:371-376.

7. Heiligenhaus A, Dohrmann J, Koch J, et al. Severe bilateral panuveitis in a patient with asymptomatic Epstein-Barr virus infection. Eye 2001;15:792-793.

8. Aburn NS, Sullivan TJ. Infectious mononucleosis presenting with dacryoadenitis. Ophthalmology 1996;103:776-778.

9. Wilhelmus KR. Ocular involvement in infectious mononucleosis: Am J Ophthalmol 1981;89:117-118.

10. Gardner BP, Margolis TP, Mondino BJ. Conjunctival lymphocytic nodule associated with the Epstein-Barr virus: Am J Ophthalmol 1991;112:567-571.

11. Feinberg AS, Spraul CW, Holden JT, et al. Conjunctival lymphocytic infiltrates associated with Epstein-Barr virus. Ophthalmology 2000;107:159-163.

RELATED ARTICLE: Key Points

* The manifestations of acute Epstein-Barr virus infection are variable.

* The classic symptoms of pharyngitis and cervical lymphadenopathy can be absent.

* The infection can present with conjunctival hemorrhage.

Zeina A. Kanafani, MD, Ziad Bashur, MD, and Souha S. Kanj, MD

From the Division of Infectious Diseases and the Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon.

Reprint requests to Dr. Souha S. Kanj, Division of Infectious Diseases, American University of Beirut Medical Center, Hamra PO Box 113-6044, Beirut 110 32090, Lebanon. Email: [e-mail]