Atypical herpes simplex virus type 2 acute retinal necrosis presentation with large subretinal lesion

Abstract

Purpose: To report the unique clinical findings of a case of Herpes Simplex Virus Type 2 herpetic retinitis manifesting as a large elevated subretinal lesion.

Observations: A 26-year-old Hispanic male with no significant past medical history presented with a one-week history of right eye pain and endorsement of worsening vision. Ophthalmic examination of the right eye identified a markedly elevated white subretinal lesion with associated findings of vitritis and hypotony. Ultrasound biomicroscopy demonstrated a diffusely thickened choroid and confirmed the observed subretinal mass. Examination of the fellow left eye was largely unremarkable with the exception of lesions suggestive of inactive chorioretinal scars. Diagnostic vitrectomy and vitreous PCR (polymerase chain reaction) was positive only for HSV-2 (herpes simplex virus type 2) and verified by two independent laboratories. The observed subretinal lesion of right eye improved on intravenous acyclovir and intravitreal foscarnet treatment.

Conclusions and importance: Presented here is an unusual, novel clinical presentation of HSV-2 acute retinal necrosis manifesting as an elevated subretinal lesion along with findings of panuveitis. This case suggests that consideration should be given to the diagnosis of HSV ARN (acute retinal necrosis) when a subretinal elevation is concomitantly appreciated in the setting of vitritis and chorioretinal lesions.

Keywords: Acute retinal necrosis; Herpes simplex virus type 2; Panuveitis; Polymerase chain reaction.

Fig. 1

Fundus photo of the right eye demonstrates a large white elevated subretinal lesion nasally with overlying dense vitritis.

Fig. 2

Ultrasonography performed at the time of presentation revealing a diffusely thickened choroid and 6.7mm hyperechoic subretinal mass corresponding to the lesion observed clinically.

Fig. 3

Montage fundus photo of the left eye demonstrating pigmented chorioretinal scars along the superior arcade.

Fig. 4

Ultrasonography performed after intravitreal and systemic viral therapy demonstrating improvement in size and morphology of the observed subretinal lesion.