Acute hemorrhagic conjunctivitis is a brief viral infection presenting with the sudden onset of ocular signs and symptoms which progress and resolve rapidly. It is typically caused by an enterovirus and was first reported in Ghana. Subsequently, cases have been reported from countries with overcrowding and unhygienic conditions as it is transmitted by the feco-oral route.
Acute hemorrhagic conjunctivitis (AHC) is a contagious and rapidly progressive viral infection reported from poor regions with unhygienic living conditions  . It is caused mainly by enterovirus 70, although coxsackievirus A24 variant, adenoviruses    and Epstein-Barr virus   have also been reported to cause it. Enteroviruses spread easily via the feco-oral route, contaminated hands/ personal items   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  . Patients present with an acute onset of ocular pain, redness of the eye, photophobia, ocular irritation with excessive lacrimation, and chemosis  . The clinical manifestations depend on the stage of the infection. In the initial stage, the patient has paranasal sinus mucosal inflammation   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 . 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  along with conjunctivitis. Infectious mononucleosis has also been associated with AHC  . 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.
- 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]
- Conjunctival Injection
Signs include lid edema, periauricular lymphadenopathy, conjunctival injection, follicular reaction, and typically subconjunctival hemorrhages. [ncbi.nlm.nih.gov]
Follicles appeared to be smaller, and the palpberal conjunctival injection was minimal ( figure 5 ). John returned for the final day 14 follow-up. He reported that his right eye continued to feel comfortable since the last visit. [reviewofcontactlenses.com]
Conjunctival injection, redness and serous or purulent discharge. Preauricular adenopathy is common. Constitutional sx include fever, malaise, nausea and vomiting. [hopkinsguides.com]
Patients demonstrate marked conjunctival injection, conjunctival chemosis (excessive edema), lid swelling and tender preauricular adenopathy. [aafp.org]
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]
- 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]
- Cranial Nerve Involvement
Other cranial nerve involvement, including primary optic atrophy, may also occur. While the pathogenesis of the neurologic sequelae remains unclear, the connection with enterovirus 70 is well established. [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   . Molecular serotyping with clinical samples has been found to be useful for rapid diagnosis, especially, during epidemics . A real-time (RT) PCR has also provided an early diagnosis in epidemics . In the case of bacterial superinfection of the cornea, microbiological culture and antibiotic sensitivity testing are performed .
However, corneal microbial superinfection has been reported after treatment with topical steroids and requires appropriate antimicrobial therapy. (See Treatment.) A secondary corneal ulcer is shown below. [emedicine.medscape.com]
You can help by adding to it. ( September 2017 ) Treatment [ edit ] There is no treatment currently available. The virus generally resolves itself within a five to seven day period. [en.wikipedia.org]
Treatment of cultures with combinations of arildone and IFN resulted in an additive inhibition of acute hemorrhagic conjunctivitis virus production. [ncbi.nlm.nih.gov]
AHC almost always resolves without sequelae, having a good visual prognosis. However, corneal microbial superinfection has been reported after treatment with topical steroids and requires appropriate antimicrobial therapy. (See Treatment.) [emedicine.medscape.com]
Treatment is symptomatic having satisfactory prognosis. Causes Of Acute Hemorrhagic Conjunctivitis Acute hemorrhagic conjunctivitis is an infectious disease affecting eyes. It is caused by coxsackie virus A 24 and enterovirus 70. [tandurust.com]
[…] habitats The local healthcare providers and local public health authorities have to ensure that the residents of a region are generally well-informed and made aware of basic preventive measures and precautions to be taken during an AHC outbreak What is the Prognosis [dovemed.com]
A total of 1 067 981 conjunctivitis cases were reported to the surveillance system for 2011; there was an increase in the number of cases in epidemiologic weeks 6-26 (summer season) versus previous years. [ncbi.nlm.nih.gov]
(See Epidemiology.) See the following for more information: [emedicine.medscape.com]
Terminology Also known as Apollo disease Epidemiology First described in Ghana in 1969 Most common in developing countries, may affect 50% of local population Pathophysiology Epidemic form is rapidly progressive and highly contagious Clinical features [pathologyoutlines.com]
The American Academy of Ophthalmology's Pathology Atlas contains virtual microscopy images of tissue samples with the following types of conjunctivitis: Chronic Follicular Conjunctivitis Granulomatous Conjunctivitis Papillary Conjunctivitis Pathophysiology [eyewiki.aao.org]
Author information 1 WHO WPRO Regional Reference Poliomyelitis Laboratory and State Key Laboratory for Molecular Virology & Genetic Engineering, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention [ncbi.nlm.nih.gov]
- Medina NH, Haro-Munoz E, Pellini AC, et al. Acute hemorrhagic conjunctivitis epidemic in Sao Paulo state, Brazil, 2011. Rev Panam Salud Publica. 2016 Feb; 39(2): 137-141
- Wu B, Qi X, Xu K, et al. Genetic characteristics of the coxsackievirus A24 variant causing outbreaks of acute hemorrhagic conjunctivitis in Jiangsu, China, 2010. PLoS One. 2014 Jan 24; 9(1):e86883
- Babalola OE, Amoni SS, Samaila E, et al. An outbreak of acute haemorrhagic conjunctivitis in Kaduna, Nigeria. Br J Ophthalmol. 1990; 74: 89–92
- Mirkovic RR, Schmidt NJ, Yin-Murphy M, Melnick JL. Enterovirus etiology of the 1970 Singapore epidemic of acute conjunctivitis. Intervirology. 1974; 4: 119–127
- Chang CH, Sheu MM, Lin KH, Chen CW. Hemorrhagic viral keratoconjunctivitis in Taiwan caused by adenovirus types 19 and 37: applicability of polymerase chain reaction-restriction fragment length polymorphism in detecting adenovirus genotypes. Cornea 2001; 20: 295–300
- Kanafani ZA, Bashur Z, Kanj SS. Acute Epstein-Barr virus infection causing bilateral conjunctival hemorrhages. South Med J. 2005;98:390-391.
- Heiligenhaus A, Dohrmann J, Koch J, et al. Severe bilateral panuveitis in a patient with asymptomatic Epstein-Barr virus infection. Eye 2001;15:792-793.
- Tavares FN, Campos RdM, Burlandy FM, et al. Molecular characterization and phylogenetic study of coxsackievirus A24v causing outbreaks of acute hemorrhagic conjunctivitis (AHC) in Brazil. PLoS One. 2011;6(8):e23206.
- Oh MD, Park S, Choi Y, et al. Acute hemorrhagic conjunctivitis caused by coxsackievirus A24 variant, South Korea, 2002. Emerg Infect Dis. 2003;9(8):1010–2.
- Ghazali O, Chua KB, Ng KP, et al. An outbreak of acute haemorrhagic conjunctivitis in Melaka, Malaysia. Singapore Med J. 2003;44(10):511–6.
- Rubenstein JB. Disorders of the conjunctiva and limbus. Yanoff MA, Duker JS, eds. Ophthalmology. Mosby; 1995. 5.1.5.
- Spencer WH, Zimmerman LE. Conjunctiva. Spencer WH, ed. Ophthalmic Pathology. 1985; 1: 130-131.
- Nilsson EC, Jamshidi F, Johansson SM, et al. Sialic acid is a cellular receptor for coxsackievirus A24 variant, an emerging virus with pandemic potential. J Virol. 2008;82(6):3061–8.
- Park SW, Lee CS, Jang HC, et al. Rapid identification of the coxsackievirus A24 variant by molecular serotyping in an outbreak of acute hemorrhagic conjunctivitis. J Clin Microbiol. 2005 Mar; 43(3):1069-71.
- Oberste MS, Maher K, Kilpatrick DR, et al. Typing of human enteroviruses by partial sequencing of VP1. J Clin Microbiol. 1999 May; 37(5):1288-93.
- Nigrovic LE, Chiang VW. Cost analysis of enteroviral polymerase chain reaction in infants with fever and cerebrospinal fluid pleocytosis. Arch Pediatr Adolesc Med. 2000 Aug; 154(8):817-21.
- Xiao XL, Wu H, Li YJ, et al. Simultaneous detection of enterovirus 70 and coxsackievirus A24 variant by multiplex real-time RT-PCR using an internal control. J Virol Methods. 2009 Jul; 159(1):23-8.
- Vajpayee RB, Sharma N, Chand M, et al. Corneal superinfection in acute hemorrhagic conjunctivitis. Cornea. 1998 Nov; 17(6):614-7.