RECURRENT HERPES VIRUS (HSV) KERATITIS IN IMMUNODEFICIENCY (MORBUS WALDENSTROM) - CASE REPORT

Herpes Keratitis is viral corneal inflammation(Herpes Simplex type1(HSV), rarely zoster virus(VZV)),which can cause corneal blindness. Recurrent herpetic corneal infections are divided based on the localization of pathological changes into superficial inflammation(punctiform keratitis, dendritic keratitis, keratitis herpetica geographica, keratitis ameboides) and stromal corneal inflammation(interstitial keratitis, necrotizing stromal herpetic keratitis and disciform keratitis). All forms are consequence of presence/replication of HSV type1 in corneal epithelial cells/immune reaction of the stroma.

Activated HSV leaves the trigeminal ganglion infecting the target tissue: keratocytes/corneal epithelial cells. Human herpesviruses(HHV) can be α,β,γ-subfamilies, causing infections in congenital T/B cell disorders, due to abnormal number/function of leukocyte subpopulations(CD4, CD8, NK). The γ-subfamily has a high oncological potential. Immunodeficiency increases the risk and recurrence rate of herpetic keratitis.

Waldenstrom macroglobulinemia is a type of non-Hodgkin lymphoma that affects two types of B cells: lymphoplasmacytic/plasma cells, with increased circulating immunoglobulinM due to gene mutation. Hyperviscosity syndrome causes bleeding of retina, fatigue, headache, lymphadenopathy.

Patient treated:Health Center/University Clinical Center Nis(Clinic for Ophthalmology).

Patient(MJ,1962)diagnosed Morbus Waldestrom(2009), in remission, occasional fatigue. First ophthalmologist visit March2023(red eye, foreign body sensation). VA=1.0;slit:Lamp(punctiform fluorescein staining, decreased corneal sensitivity,CA no flare).With therapy(2weeks)- neat finding. October2023(Red eye, blepharospasam)VA=1.0 VA left eye=0.8; Slit lamp:Cornea with dendritc branch infiltrated, fluorescein staining. Cornea insensitive. Herpes infection therapy for 6 weeks. Control:long-term stromal edema, subepithelial infiltrate.TBUT OS=7s. Next Recurrence August2024. VA=0.9-1.0 slit lamp:punctate corneal discoloration, reduced sensitivity, stromal edema. Local therapy 4 weeks finding neat.

Patient treated topically(ointment aciclovir,moxifloxacin, atropine,hyaluronic acid, NaCl5%);tbl Aciclovir(2 months, after second attack-4 months prophylactically). Resorption of subepithelial infiltrates/reduction of edema centrally.Laboratory:Nov(2023).IgM=23(0.4-2.3.4)CRP=55.6 haptoglobin=2.76. March 2024. IgM=21.2;Th Allopurinol.AFP=5.4;CEA(1.6).

Condition of congenital immunodeficiency with a slow progressive evolution. Dg:haematologist:C88.Malignant immunoproliferative diseases in which the recurrent frequent herpetic keratitis(first/last attack as a punctiform form and the second prolonged Keratitis Herpetica dendritica. Treated with local and systemic antiviral therapy resulted to epithelialization of the cornea without central opacification. The underlying disease is stable.Oncological markers are also normal. Immunodeficiency causes frequent recurrences so requires frequent follow-up.