title: HSV-1--induced acute retinal necrosis syndrome presenting with severe inflammatory orbitopathy, proptosis, and optic nerve involvement.
abstract: OBJECTIVE
  To present a unique case in which orbital inflammation, proptosis, and optic neuritis were the initial symptoms of acute retinal necrosis (ARN). The clinical presentation of ARN, as well as the currently recommended diagnostic procedures and guidelines for medical treatment of ARN, are summarized.
  
  
  METHODS
  Interventional case report.
  
  
  METHODS
  Polymerase chain reaction (PCR) techniques were made on the vitreous for cytomegalovirus, Epstein-Barr virus, herpes simplex virus (HSV), varicella zoster virus, and toxoplasmosis. A full laboratory evaluation was made together with HLA-typing and serologic tests measuring convalescent titers for HSV and other micro-organisms. Magnetic resonance imaging scan, computed tomography (CT) scan, and fluorescein angiographic examination were performed. The patient was treated with acyclovir and oral prednisone.
  
  
  METHODS
  The patient was evaluated for initial and final visual acuity and for degree of proptosis, periocular edema, and vitreitis.
  
  
  RESULTS
  The first symptoms and signs of ARN were eye pain, headache, proptosis, and a swollen optic nerve on CT scan. Other than increased C-reactive protein, all blood samples were normal. PCR was positive for HSV-type I in two separate vitreous biopsies. The patient had the strongly ARN-related specificity HLA-DQ7.
  
  
  CONCLUSIONS
  This is the first report of HSV-induced ARN presenting with inflammatory orbitopathy and optic neuritis. Polymerase chain reaction for HSV-1 was positive more than 4 weeks after debut of symptoms, which is a new finding. The combination of severe vitreitis and retinal whitening, with or without proptosis, should alert the clinician to the possibility of herpes infection and treatment with intravenous acyclovir started promptly.
authors.affiliation: The University Eye Clinic at Rigshospitalet, Copenhagen, Denmark.
authors.forename: N R
authors.initials: NR
authors.lastname: Tornerup
authors.forename: A
authors.initials: A
authors.lastname: Fomsgaard
authors.forename: N V
authors.initials: NV
authors.lastname: Nielsen
mesh_terms: D000212:Acyclovir / Q000627:therapeutic use; D000328:Adult; D000914:Antibodies, Viral / Q000032:analysis; D004279:DNA, Viral / Q000032:analysis; D005094:Exophthalmos / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D015828:Eye Infections, Viral / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D005260:Female; D005451:Fluorescein Angiography; D006561:Herpes Simplex / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D018259:Herpesvirus 1, Human / Q000235:genetics / Q000276:immunology / Q000302:isolation & purification*; D006801:Humans; D008279:Magnetic Resonance Imaging; D009902:Optic Neuritis / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D016727:Orbital Pseudotumor / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D016133:Polymerase Chain Reaction; D011239:Prednisolone / Q000627:therapeutic use; D015882:Retinal Necrosis Syndrome, Acute / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D014057:Tomography, X-Ray Computed; D014822:Vitreous Body / Q000821:virology
chemical_list: D000914:Antibodies, Viral; D004279:DNA, Viral; D011239:Prednisolone; D000212:Acyclovir