Tag: HIV

Herpes Zoster Ophthalmicus in Africa

In EnglishHerpes zoster ophthalmicus involves V1 cranial nerve (n.ophthalmicus). Here are three examples of herpes zoster in 2 young men and one 7yo girl. Both men are HIV-positive (this must be an AIDS-stage). HZO is definitely second quickest germ to penetrate and destroy the cornea. Pseudomonas has no chance in comparison to those two. HIV is certainly a boost for the fulminant clinic.

in Russian / по-русскиГерпес зостер c вовлечением первой ветви из моей африканской практики. Случай у двух взрослых мужчин и у девочки 7 лет (активный у мужчин, и в исходе у девочки). Herpes zoster ophthalmicus – наверное второй по скорости разъедания роговицы после гонококковой инфекции. Синегнойная палочка определённо нервно курит в сторонке. Мужчины были однозначно ВИЧ-положительны, а это, как известно, означает стадию СПИД. И это конечно одна из основных причин для такой яркой и драматической клинической картины.

Advanced herpes zoster ophthalmicus with corneal melt and lens/uvea prolapse. HIV positive patient.

Advanced herpes zoster ophthalmicus with corneal melt and lens/uvea prolapse. HIV positive patient.

Advanced herpes zoster ophthalmicus with resultant corneal leucoma in 7yo girl.

Advanced herpes zoster ophthalmicus with resultant corneal leucoma in 7yo girl.

Advanced herpes zoster ophthalmicus with corneal melt and iris prolapse. HIV positive patient.

Advanced herpes zoster ophthalmicus with corneal melt and iris prolapse. HIV positive patient. Failed conjunctival flap adherence depicted.

Eye precancerous lesions mimic benign pyogenic granuloma

Not all pyogenic granulomas are equally safe. Some of them may comprise an elements of ocular surface squamous neoplasia, OSSN (conjunctival intraepithelial neoplasia, CIN). The paper Herwig-Carl MC, Grossniklaus HE, Müller PL, et al. Br J Ophthalmol Epub. doi:10.1136/ bjophthalmol-2018-312960 highlighted 9 such cases.

OSSN is extremely common in the areas with widespread HIV-prevalence. Human papilloma virus is responsible for this, as a typical opportunistic infection. Knowledge of the potential of OSSN to mimic pterygia and pyogenic granulomas is crucial, especially for the mid level ophthalmic personnel, as they are the primary surgeons for these conditions in many areas.

Pyogenic Granuloma Associated With Conjunctival Epithelial Neoplasia: Report of Nine Cases

Aims: To systematically describe the clinical and histopathological features of a case series of conjunctival carcinomatous lesions underlying as-and also masquerading-pyogenic granuloma.

Methods: Nine cases of conjunctival carcinomatous lesions underlying a pyogenic granuloma (which were clinically predominant) were retrospectively identified. Patients’ records were analysed for demographic data, clinical appearance and the postoperative course. Formalin-fixed paraffin-embedded specimens were routinely processed and stained with H&E and periodic acid-Schiff. Immunohistochemical stains for cytokeratin were performed in selected cases.

Results: All nine tumours were located in the conjunctiva (bulbar, tarsal, limbal conjunctiva) of patients between 44 and 80 years. The lesions exhibited clinical features of pyogenic granuloma which dominated the clinical appearance. Additional features comprised a papillomatous appearance of the adjacent conjunctiva, a more whitish aspect of the lesion and a history of squamous cell carcinoma (SCC) respectively surgery for other entities. Histopathological analysis revealed a carcinomatous lesion (conjunctival intraepithelial neoplasia or SCC) at the base of a classic pyogenic granuloma in all nine cases. Surgical removal (R0 resection) was performed. Three cases received adjuvant mitomycin C or interferon α2b treatment. Two lesions locally recurred within 2 years after initial presentation.

Conclusion: Carcinomatous lesions may be accompanied by a pyogenic granuloma which may dominate the clinical pictures. As the tumour is usually located at the base of the lesion, a complete surgical excision followed by histopathological analysis is mandatory for each lesion appearing as conjunctival pyogenic granuloma.

Keywords: conjunctival intraepithelial neoplasia; histology; pyogenic granuloma; squamous cell carcinoma; tumour.

Primary Vitreoretinal Lymphoma in HIV Infection.

Steffen J1, Coupland SE2,3, Smith JR4.
Author information:
1. Division of Ophthalmology, University of Cape Town, Cape Town, South Africa.
2. Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
3. Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
4. Eye and Vision Health, Flinders University, Adelaide, Australia.

Abstract

Purpose: To describe the epidemiology, clinical characteristics, diagnosis and treatment of human immunodeficiency virus (HIV)-related primary vitreoretinal lymphoma (PVRL).Methods: Narrative literature review.Results: HIV-related PVRL occurs in persons who are relatively young and generally have very low CD4+ T-cell counts. Vitritis with subretinal or sub-retinal pigment epithelial infiltrates is typical. Vitreous cytology remains the gold standard for diagnosis, supplemented by flow cytometry and genetic analyses of tumor cells, and measurement of aqueous or vitreous interleukin-10 levels. Concurrent brain involvement also may establish the diagnosis. Treatment includes antiretroviral therapy (ART), systemic chemotherapy (usually methotrexate-based) and local ocular treatment (intravitreal methotrexate, intravitreal rituximab, external beam radiotherapy). Systemic chemotherapy is of uncertain value for PVRL without other central nervous system involvement. Prognosis is poor, but has improved significantly compared to the pre-ART era. Conclusions: Ophthalmologists should consider the diagnosis of PVRL in HIV-positive individuals who present with intermediate or posterior uveitis.

PMID: 32453669

Anterior chamber and iris granuloma in newly diagnosed HIV+ kid

This was a case of Mai 2016. Eleven y.o. boy came to our outpatient department with the father complaining of “growth” in one of boy’s eyes, that was allegedly present already for 2 weeks. Visual acuity 6/9 and there were no pains except photophobia.  On examination – solid feathery cream-colored mass in the AC, adherant to the iris. Yellowish behind. No anterior chamber cells, no flare, absolutely quiet eye. Upon the HIV-test she was confirmed newly positive.

presumed aspergillosis iris-AC granuloma

presumed aspergillosis iris-AC granuloma

She was started on steroid and cycloplegic topical eye drops and NSAID tablets, and in 5 days the exudate was gone. But the iris cyst remained in place. There was no vitreous or retinal involvement, and the IOP was OK.

presumed aspergillosis iris-AC granuloma after tx, note torn posterior synechiae

presumed aspergillosis iris-AC granuloma after tx: UBM-scan

Differential diagnosis: intraocular medulloepithelioma (must be congenital, but looks similar, although originating mostly from the angle or ciliary body, not the iris), intraocular lymphoma (looks simmilar, but much more scary!), tuberculoma, leproma, nonpigment melanoma or primary iris tumors, toxoplasmosis gumma, metastases in the iris (lungs, intestine, kidneys), fungi!

Other useful resources  to review iris cysts:

eyewiki.aao.org/Iris_Cysts
bjo.bmj.com/content/59/5/276.full.pdf
https://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2010-0669-RS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872564/

Literature search at that time in 2016 showed one paper from 2009 by Jain V with a similar case, Aspergillus iris granuloma: a case report with review of literature, claiming that to 2009 only three cases of aspergillosis of the anterior segment of the eye had been ever published. Here is a picture of their case:

Jain V, Aspergillus iris granuloma: a case report with review of literature. 2009

Our patient was left on the same topical treatment further in attempt to conquer the cyst and lost to follow-up. Unfortunately or fortunately, no iris-biopsy was performed that time, and therefore I had no microbiological evidence of fungi. One must also consider, that no natamycin was readily available topically in Western Province of Zambia that time, and in most of the times one must rely on antifungal activity of povidone-iodine eye drops (which are good and readily available hand made, by the way). One must strongly consider the lungs screening (CXR or CT) in immunocompromised patients, to exclude the primary source of hematogenous dissemination to
the brain or meninges. The immune status must be supported of course (f.e. HAART).

I thank my peer-colleagues from Terra-Ophthalmica for the kind help with the differential diagnosis and additional ideas for this case.