Acute Hemorrhagic Conjunctivitis

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.

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].

1. 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
2. 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
3. Babalola OE, Amoni SS, Samaila E, et al. An outbreak of acute haemorrhagic conjunctivitis in Kaduna, Nigeria. Br J Ophthalmol. 1990; 74: 89–92
4. Mirkovic RR, Schmidt NJ, Yin-Murphy M, Melnick JL. Enterovirus etiology of the 1970 Singapore epidemic of acute conjunctivitis. Intervirology. 1974; 4: 119–127
5. 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
6. Kanafani ZA, Bashur Z, Kanj SS. Acute Epstein-Barr virus infection causing bilateral conjunctival hemorrhages. South Med J. 2005;98:390-391.
7. 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.
8. 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.
9. 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.
10. 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.
11. Rubenstein JB. Disorders of the conjunctiva and limbus. Yanoff MA, Duker JS, eds. Ophthalmology. Mosby; 1995. 5.1.5.
12. Spencer WH, Zimmerman LE. Conjunctiva. Spencer WH, ed. Ophthalmic Pathology. 1985; 1: 130-131.
13. 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.
14. 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.
15. 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.
16. 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.
17. 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.
18. Vajpayee RB, Sharma N, Chand M, et al. Corneal superinfection in acute hemorrhagic conjunctivitis. Cornea. 1998 Nov; 17(6):614-7.