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Herpes Simplex: Differential Diagnoses & Workup

Author: Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Coauthor(s): Kerry Assil, MD, Medical Director and CEO, The Sinskey Eye Institute
Contributor Information and Disclosures

Updated: Feb 20, 2009

Differential Diagnoses

Chlamydia
Herpes Zoster
Conjunctivitis, Allergic
Keratitis, Bacterial
Conjunctivitis, Viral
Keratitis, Fungal
Contact Lens Complications
Keratitis, Interstitial
Corneal Abrasion
Keratoconjunctivitis, Epidemic
Corneal Graft Rejection
Ocular Manifestations of Syphilis

Other Problems to Be Considered

Impetigo
Tyrosinemia
Acanthamoeba keratitis
Staphylococcus marginal ulcer
Cogan syndrome
Measles and mumps
Neurotrophic keratitis

Workup

Laboratory Studies

  • The diagnosis is usually clinical, based on the presence of lid lesions or a characteristic dendrite.
  • If the diagnosis is in doubt, laboratory diagnosis can be made using the following:
    • Giemsa stain
    • Papanicolaou stain
    • Viral culture
    • Immunohistochemistry looking for viral antigens
    • Polymerase chain reaction (PCR)

Histologic Findings

Giemsa stain of scrapings of the corneal or skin lesions shows multinucleated giant cells. Papanicolaou stain shows intranuclear eosinophilic inclusion bodies.

More on Herpes Simplex

Overview: Herpes Simplex
Differential Diagnoses & Workup: Herpes Simplex
Treatment & Medication: Herpes Simplex
Follow-up: Herpes Simplex
References

References

  1. Carr DJ, Tomanek L. Herpes simplex virus and the chemokines that mediate the inflammation. Curr Top Microbiol Immunol. 2006;303:47-65. [Medline].

  2. Cobo LM, Coster DJ, Rice NS, Jones BR. Prognosis and management of corneal transplantation for herpetic keratitis. Arch Ophthalmol. Oct 1980;98(10):1755-9. [Medline].

  3. de Rojas Silva MV, Diez-Feijoo E, Javaloy J, Sanchez-Salorio M. Prophylactic perioperative antiviral therapy for LASIK in patients with inactive herpetic keratitis. J Refract Surg. Apr 2006;22(4):404-6. [Medline].

  4. Herpetic Eye Disease Study Group. A controlled trial of oral acyclovir for the prevention of stromal keratitis or iritis in patients with herpes simplex virus epithelial keratitis. The Epithelial Keratitis Trial. Arch Ophthalmol. Jun 1997;115(6):703-12. [Medline].

  5. Herpetic Eye Disease Study Group. A controlled trial of oral acyclovir for iridocyclitis caused by herpes simplex virus. Arch Ophthalmol. Sep 1996;114(9):1065-72. [Medline].

  6. Herpetic Eye Disease Study Group. Acyclovir for the prevention of recurrent herpes simplex virus eye disease. Herpetic Eye Disease Study Group. N Engl J Med. Jul 30 1998;339(5):300-6. [Medline].

  7. Holland EJ, Schwartz GS. Classification of herpes simplex virus keratitis. Cornea. Mar 1999;18(2):144-54. [Medline].

  8. Kabra A, Lalitha P, Mahadevan K, Prajna NV, Srinivasan M. Herpes simplex keratitis and visual impairment: a case series. Indian J Ophthalmol. Mar 2006;54(1):23-7. [Medline].

  9. Kaiserman I, Kaiserman N, Nakar S, Vinker S. Herpetic eye disease in diabetic patients. Ophthalmology. Dec 2005;112(12):2184-8. [Medline].

  10. Kaufman HE, Martola EL, Dohlman CH. Herpes simplex treatment with IDU and corticosteroids. Arch Ophthalmol. 1963;69:468-72.

  11. Koelle DM, Ghiasi H. Prospects for developing an effective vaccine against ocular herpes simplex virus infection. Curr Eye Res. Nov 2005;30(11):929-42. [Medline].

  12. Kothari MT, Mehta BK, Asher NS, Kothari KJ. Recurrence of bilateral herpes simplex virus keratitis following bimatoprost use. Indian J Ophthalmol. Mar 2006;54(1):47-8. [Medline].

  13. Levy J, Lapid-Gortzak R, Klemperer I, Lifshitz T. Herpes simplex virus keratitis after laser in situ keratomileusis. J Refract Surg. Jul-Aug 2005;21(4):400-2. [Medline].

  14. Li H, Zhang J, Kumar A, Zheng M, Atherton SS, Yu FS. Herpes simplex virus 1 infection induces the expression of proinflammatory cytokines, interferons and TLR7 in human corneal epithelial cells. Immunology. Feb 2006;117(2):167-76. [Medline].

  15. Liesegang TJ, Melton LJ 3rd, Daly PJ, Ilstrup DM. Epidemiology of ocular herpes simplex. Incidence in Rochester, Minn, 1950 through 1982. Arch Ophthalmol. Aug 1989;107(8):1155-9. [Medline].

  16. Lu CK, Chen KH, Lee SM, Hsu WM, Lai JY, Li YS. Herpes simplex keratitis following excimer laser application. J Refract Surg. May 2006;22(5):509-11. [Medline].

  17. Miserocchi E, Modorati G, Galli L, Rama P. Efficacy of valacyclovir vs acyclovir for the prevention of recurrent herpes simplex virus eye disease: a pilot study. Am J Ophthalmol. Oct 2007;144(4):547-51. [Medline].

  18. Pepose JS, Keadle TL, Morrison LA. Ocular herpes simplex: changing epidemiology, emerging disease patterns, and the potential of vaccine prevention and therapy. Am J Ophthalmol. Mar 2006;141(3):547-557. [Medline].

  19. Prabriputaloong T, Margolis TP, Lietman TM, Wong IG, Mather R, Gritz DC. Atopic disease and herpes simplex eye disease: a population-based case-control study. Am J Ophthalmol. Nov 2006;142(5):745-9. [Medline].

  20. Rao SN. Treatment of herpes simplex virus stromal keratitis unresponsive to topical prednisolone 1% with topical cyclosporine 0.05%. Am J Ophthalmol. Apr 2006;141(4):771-2. [Medline].

  21. Saini JS, Agarwala R. Clinical pattern of recurrent herpes simplex keratitis. Indian J Ophthalmol. Mar 1999;47(1):11-4. [Medline].

  22. Seitzman GD, Cevallos V, Margolis TP. Rose bengal and lissamine green inhibit detection of herpes simplex virus by PCR. Am J Ophthalmol. Apr 2006;141(4):756-8. [Medline].

  23. Sozen E, Avunduk AM, Akyol N. Comparison of efficacy of oral valacyclovir and topical acyclovir in the treatment of herpes simplex keratitis: a randomized clinical trial. Chemotherapy. 2006;52(1):29-31. [Medline].

  24. Tabbara KF. Treatment of herpetic keratitis. Ophthalmology. Sep 2005;112(9):1640. [Medline].

  25. Wilhelmus KR. Diagnosis and management of herpes simplex stromal keratitis. Cornea. 1987;6(4):286-91. [Medline].

  26. Wilhelmus KR, Gee L, Hauck WW, et al. Herpetic Eye Disease Study. A controlled trial of topical corticosteroids for herpes simplex stromal keratitis. Ophthalmology. Dec 1994;101(12):1883-95; discussion 1895-6. [Medline].

  27. Zaher SS, Sandinha T, Roberts F, Ramaesh K. Herpes simplex keratitis misdiagnosed as rheumatoid arthritis-related peripheral ulcerative keratitis. Cornea. Nov 2005;24(8):1015-7. [Medline].

Further Reading

Keywords

herpes simplex, herpes simplex virus, HSV, keratitis, corneal ulcer, dendrite, conjunctivitis

Contributor Information and Disclosures

Author

Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society
Disclosure: WebMD/eMedicine Salary Employment

Coauthor(s)

Kerry Assil, MD, Medical Director and CEO, The Sinskey Eye Institute
Kerry Assil, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Association for Research in Vision and Ophthalmology, and Contact Lens Association of Ophthalmologists
Disclosure: Nothing to disclose.

Medical Editor

Kilbourn Gordon III, MD, FACEP, Urgent Care Physician
Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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