Acute hemorrhagic conjunctivitis (AHC) is a contagious and rapidly progressive viral infection reported from poor regions with unhygienic living conditions [1] [2]. It is caused mainly by enterovirus 70, although coxsackievirus A24 variant, adenoviruses [3] [4] [5] and Epstein-Barr virus [6] [7] have also been reported to cause it. Enteroviruses spread easily via the feco-oral route, contaminated hands/ personal items [8] [9] and vertically between mother and child.

AHC has an incubation period ranging from 12 hours to 2 days and the self-limiting disease can last for up to two week [9] [10]. Patients present with an acute onset of ocular pain, redness of the eye, photophobia, ocular irritation with excessive lacrimation, and chemosis [8] [10]. The clinical manifestations depend on the stage of the infection. In the initial stage, the patient has paranasal sinus mucosal inflammation [11] [12] followed by the appearance of petechia on the conjunctiva. Subsequently, these may form subconjunctival hemorrhages and are accompanied by follicular conjunctivitis, eyelid edema, and induration. In the early part of the AHC infection, the inflammatory response is monocellular and watery and changes to a blood stained response with the progression of the infection [12]. The corneal signs include epithelial keratitis and subepithelial opacities. Occasionally, enterovirus infection has been reported to cause acute lower limb flaccid paralysis, cranial nerve palsies and radiculomyelitis [13] along with conjunctivitis. Infectious mononucleosis has also been associated with AHC [6] [7]. AHC symptoms usually resolve in 2 weeks and sequelae are rare.

Enteroviral infection in infants can present as low-grade fever of unspecified etiology and can involve other organs like the myocardium, lungs, central nervous system and the skin.

• Red Eye

  This article aims at increasing public awareness by elaborating two diseases (Acute Hemorrhagic Conjunctivitis and Paederus spp keratoconjuctivitis, periorbital oedema-"Nairobi red eyes") confused by many as being associated with recurrent epidemics of [ncbi.nlm.nih.gov]

  When infected with AHC, patients will experience painful, red eyes, swelling of the conjunctival tissue, and frequent mucus discharge from the eyes accompanied by excessive tearing and subconjunctival hemorrhaging. [en.wikipedia.org]

  Virgin Islands, September-October 1998. ( 9810014 ) 1998 46 Acute red eye. [malacards.org]

• Excessive Tearing

  Abstract Acute hemorrhagic conjunctivitis (AHC) is an epidemic form of highly contagious conjunctivitis and is characterized by sudden onset of painful, swollen, red eyes, with conjunctival hemorrhaging and excessive tearing. [ncbi.nlm.nih.gov]

  When infected with AHC, patients will experience painful, red eyes, swelling of the conjunctival tissue, and frequent mucus discharge from the eyes accompanied by excessive tearing and subconjunctival hemorrhaging. [en.wikipedia.org]

  The most common reported symptom was excessive tearing of the eye or epiphora (92.9%) followed by conjunctival hyperemia (65.8%), photophobia (54.1%), subconjunctival hemorrhage (48.1%), eye pain (47.5%), and palpebral chemosis (36.4%). [scholarworks.gsu.edu]

  Acute hemorrhagic conjunctivitis (AHC) is an epidemic form of highly contagious conjunctivitis and is characterized by sudden onset of painful, swollen, red eyes, with conjunctival hemorrhaging and excessive tearing. [cdc.gov]

  Most infected persons will complain of painful red eyes and frequent mucus discharge from the eyes accompanied by excessive tearing. Some also experience blurry vision and fever in addition to the common symptoms. [ghanaweb.com]

• Blepharitis

  Blepharokeratoconjunctivitis is the combination of conjunctivitis with blepharitis and keratitis. [en.wikipedia.org]

  Mild itching can also be a feature of blepharitis, dry eyes and, occasionally, bacterial or viral conjunctivitis. [aafp.org]

  Other signs, such as dermatitis of the lid skin, inflammation of the lid margin (blepharitis), conjunctival scarring, and involvement of the cornea occur only in certain of the most severe disorders. [eyewiki.aao.org]

  For example, smallpox vaccinations, though currently uncommon due to the disease's eradication, result in ocular vaccinia in about one per 40,000 vaccinations. 14 Aside from occurring in those with compromised immune systems, blepharitis, conjunctivitis [reviewofophthalmology.com]

  Viral culture Viral PCR Adenovirus conjunctivitis diagnosed by rapid, 10-min office test (AdenpPlus) DDx for non-conjunctivitis causes include subconjunctival hemorrhage, blepharitis, eyelid disorders, scleritis, episcleritis, keratitis, pterygium, acute [hopkinsguides.com]

• Conjunctival Disease

  Cefpodoxime or cefixime not primarily recommended but may be alternative oral treatment instead of ceftriaxone for uncomplicated GC infection, but no clinical data supporting effectiveness for conjunctival disease. [hopkinsguides.com]

• Conjunctival Petechiae

  As the name “acute hemorrhagic conjunctivitis” suggests, conjunctival petechiae are often found. [reviewofcontactlenses.com]

• Suggestibility

  These data suggest that enterovirus 70 was the etiologic agent of the acute hemorrhagic conjunctivitis outbreak in Puerto Rico. [ncbi.nlm.nih.gov]

• Flaccid Paralysis

  Occasionally, enterovirus infection has been reported to cause acute lower limb flaccid paralysis, cranial nerve palsies and radiculomyelitis along with conjunctivitis. Infectious mononucleosis has also been associated with AHC. [symptoma.com]

  West Nile virus-associated flaccid paralysis outcome. Emerg Infect Dis 2006;12:514-6. [Figure 1] [annalsofian.org]

  The neurologic manifestations vary from a transient, mild cranial nerve palsy to painful lumbosacral radiculomyelitis with temporary or permanent flaccid paralysis. [drplace.com]

• Neurologic Manifestation

  The neurologic manifestations vary from a transient, mild cranial nerve palsy to painful lumbosacral radiculomyelitis with temporary or permanent flaccid paralysis. [drplace.com]

The clinical course of AHC is very rapid and resolves spontaneously, often without treatment. Hence the workup and laboratory tests have to be performed fast. Clinical suspicion, history and, a detailed ophthalmic examination remain the mainstay of diagnosis.

Studies for rapid viral detection are necessary to identify the causative organism and they are still being improved. Polymerase chain reaction (PCR) assays are supplanting standardized neutralizing antisera assays. Specimens from conjunctival swabs are used to identify the etiology of AHC [14] [15] [16]. Molecular serotyping with clinical samples has been found to be useful for rapid diagnosis, especially, during epidemics [14]. A real-time (RT) PCR has also provided an early diagnosis in epidemics [17]. In the case of bacterial superinfection of the cornea, microbiological culture and antibiotic sensitivity testing are performed [18].

• Fusarium

  Organisms isolated were Pseudomonas aeruginosa (three eyes, 25%), Fusarium species (three eyes, 25%), Aspergillus species (two eyes, 16%), and Staphylococcus aureus (two eyes, 16%). Mixed infection occurred in two patients. [ncbi.nlm.nih.gov]

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