Epidemic keratoconjunctivitis (EK), defined as a highly contagious infection of the eye surface (the conjunctiva and associated tissues), is caused by double-stranded DNA adenoviruses [1] [2]. More than 50 adenoviruses have been described in the literature, but serotypes 8, 19, and 37 are established as main pathogens of EK [2] [3] [4]. Because of their resistance to the majority of disinfectants and heat tolerance (they are able to survive at room temperature), adenoviruses are potent causes of epidemic infections and outbreaks, one of them being epidemic keratoconjunctivitis [3]. Humans are the only known reservoir of adenoviruses, and person-to-person transmission is achieved through direct or close contact with individuals (mainly tear fluids) who are actively shedding the virus when exhibiting signs and symptoms, while some studies have established that individuals remain infectious even a few weeks after resolution of symptoms [1] [2] [3]. After an incubation period that lasts for about 2-12 days, the clinical presentation is distinguished by a severe inflammatory process that leads to redness of the eye accompanied by irritation, excessive tearing and discharge that causes blurred vision, as well as photophobia and a sensation of foreign body presence [2] [3] [5] [6]. EK initially affects only one eye, but it may spread to the other eye as well, although with a much milder presentation [2]. In some patients, generalized symptoms in the form of fever, headaches, proximal lymphadenopathy appear (preauricular lymph nodes are most often involved), but the prognosis is generally self-limiting [2] [3] [5]. EK is predominantly reported in crowded areas (eg. schools, health-care institutions, but also pools due to poorly chlorinated water that contains adenovirus particles) and has no seasonal predilection [2] [6].

• Fever

  EKC patients may complain about influenza-like symptoms, including fever, malaise, respiratory symptoms, nausea, vomiting, diarrhea, and myalgia. [genome.jp]

  Redness of the eye, as well as photophobia, blurred vision, ocular discharge, and in some cases, constitutional symptoms such as fever and lymphadenopathy, are described as main complaints. [symptoma.com]

  Symptoms: Foreign body sensation, photophobia, conjunctival hyperemic, eyelid stuck together in the morning, eyelid edema and sero-fibrinous discharge Ocular symptoms commonly preceded by systemic symptoms of fever, sore throat and sometimes gastrointestinal [dro.hs.columbia.edu]

  […] blurred vision and lymphadenopathy by the ear nearest the affected eye.[2] It is often associated with a sore throat and stuffy and runny nose, mainly in adults.[3] A type of adenoviral keratoconjunctivitis in very young children can present with a high fever [en.wikipedia.org]

  Family of adenoviruses contain different serotypes that can also cause pharyngoconjunctival fever, non-specific sporadic follicular conjunctivitis and chronic papillary conjunctivitis. [aimu.us]

• Malaise

  EKC patients may complain about influenza-like symptoms, including fever, malaise, respiratory symptoms, nausea, vomiting, diarrhea, and myalgia. [genome.jp]

  Presentation Often, EKC initially manifests as a flu-like syndrome consisting of fever, malaise, and myalgias followed by the appearance of ocular signs and symptoms, including a red eye, eyelid edema, excessive tearing, irritation, foreign body sensation [aao.org]

  – General malaise. – Myalgia. – Nausea. – Vomiting. – Diarrhoea. Ocular features of EKC: Symptoms tend to last for 7-21 days. More than half the cases show involvement of fellow eye within 7 days of onset. [aimu.us]

  […] teeth (dark), reduced caries rate signs and symp - poor growth, malabsorption, steatorrhea, COPD, clubbed fingers/toes, barrel chest inflammation of bone marrow and adj. bone, caused by Staphylococci due to trauma/surgery signs - pain, red, swelling, malaise [brainscape.com]

• Rigor

  This outbreak clearly demonstrates the efficacy of rigorous infection control in preventing nosocomial transmission of adenovirus EKC. [ncbi.nlm.nih.gov]

  […] treatment.23,24,25 Both a high number of cases and a long period before the outbreak is resolved have been characteristic in other EKC outbreaks described in the literature reflecting the difficulty of controlling transmission despite the establishment of rigorous [webmedcentral.com]

• Chills

  […] platelets and thrombosis in terminal arterioles and capillaries rdxn in # of neutrophils -LEUKOPENIA with rdxn in # of PMNs -toxic effect of certain ANTITHYROID DRUGS (propylthiouracil, methimazole, carbimazole) WBC < 2000, almost no nutrophils -high fever, chills [brainscape.com]

• Pneumonia

  References: [1] [2] [3] [4] [5] [6] [7] [8] [9] Bacterial conjunctivitis General Etiology : Staphylococc us aureus (most common in adults), Streptococcal pneumoniae, Haemophilus influenzae, Pseudomonas, Haemophilus, and Moraxella catarrhalis Clinical [amboss.com]

  Most commonly, they cause a variety of respiratory infections from bronchitis, to croup, to pneumonia. [webmedcentral.com]

  HAdV-56 was first identified in a 10-day-old neonate who died from fatal pneumonia. Ten days after death, three health care providers developed EKC [15]. [journals.plos.org]

  Common organisms include Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Haemophilus influenzae in children. [medicalstudy.blogspot.com]

  […] vesicles nodules of epithelioid cells that are modified macrophages with eosinophilic tyoplasm Granulomatous infxns include mycobacterial diseases fungal parasitic syphilis silicosis and berylliosis sarcoidosis acute/chronic inflammation is involved with pneumonia [brainscape.com]

• Myalgia

  EKC patients may complain about influenza-like symptoms, including fever, malaise, respiratory symptoms, nausea, vomiting, diarrhea, and myalgia. [genome.jp]

  […] to adenovirus B30.2 Viral pharyngoconjunctivitis B30.3 Acute epidemic hemorrhagic conjunctivitis (enteroviral) B30.8 Other viral conjunctivitis B30.9 Viral conjunctivitis, unspecified B33 Other viral diseases, not elsewhere classified B33.0 Epidemic myalgia [icd10data.com]

  Presentation Often, EKC initially manifests as a flu-like syndrome consisting of fever, malaise, and myalgias followed by the appearance of ocular signs and symptoms, including a red eye, eyelid edema, excessive tearing, irritation, foreign body sensation [aao.org]

  – Myalgia. – Nausea. – Vomiting. – Diarrhoea. Ocular features of EKC: Symptoms tend to last for 7-21 days. More than half the cases show involvement of fellow eye within 7 days of onset. The signs and symptoms are less severe in the fellow eye. [aimu.us]

• Corneal Opacity

  RESULTS: Four patients in our clinic underwent a corneal ulcer treatment following suspected EKC. Each developed a monocular corneal opacity. Three patients with a chief complaint of corneal opacity were transferred to our clinic from other clinics. [ncbi.nlm.nih.gov]

• Conjunctival Injection

  Case Presentation A 67-year-old man was referred to Oculoplastics after suffering from conjunctival injection and chemosis in the right eye for 4 days. [karger.com]

  RESULTS: After a mean of 1.8 ± 0.7 days of oral steroid treatment, eyelid edema, corneal damage, conjunctival injection, follicles, and chemosis improved in all patients. [ncbi.nlm.nih.gov]

  The hazard for resolution of lid edema (HR 0.41, adj.p=0.009), bulbar conjunctival injection (HR 0.55, adj.p=0.009), abnormal tear meniscus (HR 0.56, p=0.007), tearing (HR 0.54, adj p [digital.lib.washington.edu]

  The right eye had a 1+ conjunctival injection compared with her left eye’s 3+ conjunctival injections of multiple petechial hemorrhages. There was a bilateral inferior palpebral folliculitis. Visual acuity measured 6/6 OD and 6/7.5 OS. [webmedcentral.com]

  Note crusting, lid swelling, and conjunctival injection. Diagnosis Diagnosis of EKC is typically made on clinical presentation. [aao.org]

• Excessive Tearing

  tearing Follicular reaction Foreign body sensation This disorder is caused by a small virus and therefore has no specific treatment. [flei.com]

  Other classic features are burning, foreign body sensation, excessive tearing, and photophobia. [amboss.com]

  After an incubation period that lasts for about 2-12 days, the clinical presentation is distinguished by a severe inflammatory process that leads to redness of the eye accompanied by irritation, excessive tearing and discharge that causes blurred vision [symptoma.com]

  Presentation Often, EKC initially manifests as a flu-like syndrome consisting of fever, malaise, and myalgias followed by the appearance of ocular signs and symptoms, including a red eye, eyelid edema, excessive tearing, irritation, foreign body sensation [aao.org]

  During the first five days of active disease there is pain/discomfort, redness of the white part of the eye and excessive tearing (watery/serous discharge from the eyes). [mastereyeassociates.com]

• Eye Pain

  Symptoms of EKC include a feeling that something is in the eye; redness, irritation and itchiness of the eyes; clear or yellow drainage that may make the eyelids stick together; swelling of the eyelids; sensitivity to light; blurred vision and eye pain [outbreaknewstoday.com]

  The symptoms of epidemic keratoconjunctivitis can commence in one or both eyes and include: redness ("pink eye") swelling of the eyelids sensitivity to light (photophobia) clear, watery discharge blurred vision eye pain, or a feeling that something is [health.nsw.gov.au]

  Sticky eyelids, which are difficult to keep open Eye pain and inflammation; with gritty feeling of sand-like particles inside the eye Continuous discharge of watery mucus from the eyes Blurred vision, light sensitivity Certain indications like fever, [dovemed.com]

  More than half the cases show involvement of fellow eye within 7 days of onset. The signs and symptoms are less severe in the fellow eye. In more severe cases, patient may present with ocular and peri-orbital pain and diminution of vision. [aimu.us]

  Mixed papillary and follicular response of the conjunctiva, eye pain, burning eyes, itching of the eyes, diffuse hyperemia, chemosis, serous discharge and ipsilateral periauricular lymphadenopathy can be observed during the course of the disease. [bmcophthalmol.biomedcentral.com]

• Swelling of Eyelid

  Eyelids: – Swelling of eyelids. – Erythema (redness) of eyelids. [aimu.us]

  […] of eyelids that can have a negative effect on everyday life. [bmcophthalmol.biomedcentral.com]

• Headache

  In some patients, generalized symptoms in the form of fever, headaches, proximal lymphadenopathy appear (preauricular lymph nodes are most often involved), but the prognosis is generally self-limiting. [symptoma.com]

  Occasionally, people may also get: fever headache extreme tiredness swollen lymph nodes. How is it spread? Epidemic keratoconjunctivitis is highly contagious and adenoviruses can live on surfaces for up to 30 days. [health.nsw.gov.au]

  – Headache. – Body fatigue. – Lymphadenopathy (swollen lymph nodes, specifically pre-auricular) – Respiratory symptoms. – General malaise. – Myalgia. – Nausea. – Vomiting. – Diarrhoea. Ocular features of EKC: Symptoms tend to last for 7-21 days. [aimu.us]

  […] visual acuity Eyelid swelling Follicular reaction (Fig. 5 and 6) Clear or yellow discharge from the eye(s) Epithelial keratitis Systemic signs/symptoms: Lymphadenopathy (swollen nymph nodes, specifically the preauricular lymph nodes) (Fig. 8) Fever Headache [eyewiki.aao.org]

  She also complained of flu-like symptoms: swollen glands, fever and headache. Upon examination, her left eye had formed pseudomembranes under the upper lid, which would re-form rapidly after removal. [reviewofoptometry.com]

• Papilledema

  Globe rupture Keratomycosis Phthisis bulbi Persistent fetal vasculature / Persistent hyperplastic primary vitreous Persistent tunica vasculosa lentis Familial exudative vitreoretinopathy Pathways Optic nerve Optic disc Optic neuritis optic papillitis Papilledema [en.wikipedia.org]

  If the inflammation gets worse and starts to compress the central retinal artery or arterioles, papilledema or optic neuritis may occur and lead to progressive optic atrophy, which can cause significant damages to the patient's vision. [karger.com]

The differential diagnosis of eye redness and conjunctivitis is quite broad, but despite the fact that adenoviruses are one of the most important causes of this clinical entity, a thorough clinical investigation is recommended in order to raise suspicion toward an adenovirus infection [5]. Key information may be obtained during history taking when the physician should inquire whether similar symptoms have been reported by other individuals who were in close contact with the patient (eg. classmates, coworkers). Physical examination is an equally important part of the workup, during which eyelid and periorbital edema are observed, in addition to conjunctival hyperemia [2] [3] [5]. A slit-lamp examination performed by a skilled ophthalmologist can further support the diagnosis by detecting conjunctival swelling, hyperemia, and pseudomembrane formation in some cases [2]. When sufficient clinical criteria are obtained, microbiological studies need to be employed. Viral cultures carry a very successful rate of detecting viruses from patient samples, but their rather long turnaround times often requires the use of alternative methods, such as antigen detection through serology and indirect immunofluorescence [5]. But the low specificity and sensitivity of these studies (together with cultures) have placed them in an inferior position compared to newer and faster, but equally sensitive and specific methods [2]. Polymerase chain reaction (PCR), a molecular test that can yield conclusive results within a day, is widely recommended as the main method of diagnosing adenoviruses, although its cost still reduces its overall use in general practice [2] [5] [7] [8].

Patients were randomly assigned to treatment with trifluridine, dexamethasone, or artificial tears, and examined in a double-masked fashion. There was no significant difference between the results of the three treatments. [ncbi.nlm.nih.gov]

Jeng BH, Holsclaw DS (2011) Cyclosporine A 1 % eye drops for the treatment of subepithelial infiltrates after adenoviral keratoconjunctivitis. Cornea 30:958–961 CrossRef PubMed Google Scholar 6. [link.springer.com]

The format includes the CPT codes for billing purposes, short description of the condition, etiology/incidence, course/prognosis, laboratory findings, differential diagnosis; prophylaxis, treatment (local and systemic, surgical or other), miscellaneous [books.google.com]

In some patients, generalized symptoms in the form of fever, headaches, proximal lymphadenopathy appear (preauricular lymph nodes are most often involved), but the prognosis is generally self-limiting. [symptoma.com]

[…] herpes simplex virus (HSV), varicella-zoster virus ( VZV ), picornavirus, molluscum contagiosum, HIV (highly contagious) Clinical features See “Clinical features” above Epidemic keratoconjunctivitis Herpes simplex conjunctivitis Diagnosis Treatment Prognosis [amboss.com]

[…] rubbing the eyes (this may be difficult when the affected individuals are very young children) Stop or restrain yourself from smoking tobacco, or drinking alcohol The condition is seasonal/periodic, and individuals may chronically contract EKC What is the Prognosis [dovemed.com]

In general, the prognosis for visual acuity in patients with dry eye disease is good. Patients with SS or prolonged untreated dry eye represent a subgroup with a worse prognosis, requiring a longer course of treatment. [emedicine.medscape.com]

Human adenovirus species D type 37 (HAdV-D37) is an important etiologic agent of epidemic keratoconjunctivitis. Annotation of the whole genome revealed an open reading frame (ORF) in the E3 transcription unit predicted to encode a 31.6kDa protein. [ncbi.nlm.nih.gov]

Methods: Isolation of the etiologic agent was achieved using cultured African green monkey kidney epithelial cells (VERO). [molvis.org]

Further genetic analysis of serologically classified HAdV-D isolates may provide insights into the epidemiology of EKC. [ncbi.nlm.nih.gov]

Infection Control & Hospital Epidemiology ISSN: 0899-823X EISSN: 1559-6834 URL: /core/journals/infection-control-and-hospital-epidemiology × [cambridge.org]

References: [18] [19] Non-infectious conjunctivitis Ocular cicatricial pemphigoid ( OCP ) Etiology : autoimmune Epidemiology : predominantly affects older women Pathology : subepithelial blistering with subsequent scarring Symptoms/Clinical features Paroxysmal [amboss.com]

An outbreak within our institute caused by Ad8 from a disseminated source was characterized by molecular and epidemiological studies. [molvis.org]

HAdVs are known for their strong host species specificity that limits studying HAdV virulence and pathophysiology in animal models. [ncbi.nlm.nih.gov]

Despite this difference, VKC and GPC are pathophysiologically similar. [medicalstudy.blogspot.com]

Usually chronic progression ( ∼ 10–30 years from symptom onset to end stage) with periods of remission and exacerbation Individual progression on or off treatment is unpredictable (→ long term follow-up is vital) Epidemiology : common in young adults Pathophysiology [amboss.com]

In this article, well explain the pathophysiology of viral eye infection, suggest how to nail the diagnosis, and provide a step-by-step explanation of this highly effective, inexpensive, patient-friendly silver bullet EKC treatment. [reviewofoptometry.com]

Pathophysiology A genetic predisposition in SS-associated dry eye disease exists, as is evidenced by the high prevalence of human leukocyte antigen B8 (HLA-B8) haplotype in these patients. [emedicine.medscape.com]

[…] and Prevention, Rikaze City, Tibet Autonomous Region, People's Republic of China. 8 Xi'an Center for Disease Control and Prevention, Xi'an City, Shaanxi Province, People's Republic of China. [ncbi.nlm.nih.gov]

Thus, preventive strategies undertaken by clinicians are paramount in reducing infections and their public health consequences. [aao.org]

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