Acute Epstein-Barr virus infection causing bilateral conjunctival hemorrhages.Abstract: The systemic and ocular manifestations of acute Epstein-Barr virus infection are protean. Conjunctival con·junc·ti·val
Relating to the conjunctiva.
pertaining to or emanating from conjunctiva.
congenital conjunctival membrane 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
Epstein-Barr virus (EBV) is the most common causative agent of the infectious mononucleosis syndrome infectious mononucleosis 'syndrome' Any peripheral monocytosis accompanied by Sx typical of classic EBV-induced infectious mononucleosis–eg, CMV, herpes virus, HHV-6, HIV-1, Toxoplasma gondii , 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)
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 Papules
Firm bumps on the skin.
Mentioned in: Smallpox on the extremities. The liver edge could be palpated at 2 cm below the costal margin. No splenomegaly splenomegaly /sple·no·meg·a·ly/ (-meg´ah-le) enlargement of the spleen.
congestive splenomegaly Banti's disease; splenomegaly secondary to portal hypertension. or significant lymphadenopathy was noted. The white blood cell count white blood cell count,
n a diagnostic clinical laboratory test to determine the number and types of leukocytes present in a measured sample of blood. Overall the normal number of leukocytes ranges from 5000 to 10,000/mm3. 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 suffusion /suf·fu·sion/ (su-fu´zhun)
1. the process of overspreading, or diffusion.
2. the condition of being moistened or of being permeated through, as by blood. and hemorrhage in both eyes, and he had ecchymotic ec·chy·mo·sis
The passage of blood from ruptured blood vessels into subcutaneous tissue, marked by a purple discoloration of the skin.
[New Latin, from Greek lesions over the eyelids (Figure). Monospot, Weil-Felix, and antibodies against leptospira, brucella Brucella /Bru·cel·la/ (broo-sel´ah) a genus of schizomycetes (family Brucellaceae). B. abor´tus causes infectious abortion in cattle and is the most common cause of brucellosis in humans. B. , cytomegalovirus, and toxoplasma Toxoplasma /Toxo·plas·ma/ (tok?so-plaz´mah) a genus of sporozoa that are intracellular parasites of many organs and tissues of birds and mammals, including humans. T. gon´dii is the etiologic agent of toxoplasmosis. were all negative. He was started empirically on doxycycline for suspected African tick-bite fever, pending the results of specific antibodies against Rickettsia rickettsia (rĭkĕt`sēə), any of a group of very small microorganisms, many disease-causing, that live in vertebrates and are transmitted by bloodsucking parasitic arthropods such as fleas, lice (see louse), and ticks. 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.
Various ocular disease entities have been linked to EBV, including oculoglandular syndrome, (4) keratitis keratitis
Inflammation of the cornea (see eye). The conjunctiva may also be inflamed (keratoconjunctivitis). Depending on the cause, including dryness of the eye (from low tear production or inability to close the eye), chemical or physical injury, or certain , (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 polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is 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.
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.
1. Straus SE, Cohen cohen
(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male. JI, Tosato G, et al. Epstein-Barr virus infections: biology, pathogenesis, and management. Ann Intern Med 1993;118:45-58.
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4. Meisler DM, Bosworth DE, Krachmer JH. Ocular infectious mononucleosis manifested as Parinaud's oculoglandular syndrome Pa·ri·naud's oc·u·lo·glan·du·lar syndrome
Conjunctival granuloma in one eye accompanied by swelling of the lymph nodes in front of the auricle of the ear, seen in tularemia, chancre, and tuberculosis. : Am J Ophthalmol 1981;92:722-726.
5. Matoba AY, Wilhelmus KR, Jones DB. Epstein-Barr viral stromal Stromal
A type of tissue that is associated with the support of an organ.
Mentioned in: Wilms' Tumor 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 American University of Beirut, at Beirut, Lebanon; English language; chartered by New York State in 1866 as Syrian Protestant College, rechartered 1920 as the American Univ. 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: firstname.lastname@example.org