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Epidemic Keratoconjunctivitis

Epidemic keratoconjunctivitis is an infection of the eye caused by adenoviruses. The name of the condition stems from the fact that it frequently causes outbreaks, due to its ability to spread from person to person. 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. A detailed clinical and microbiological workup is necessary in order to make the diagnosis.


Presentation

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].

Splenomegaly
  • Myelogenous - granulocytes and megakaryocytes -CML is 4 yrs. with death from hemorrhage or infxn -Philadelphia chromosome and low levels of leukocyte alkaline phosphatease -massive splenomegaly 2.[brainscape.com]
Fever
  • 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]
  • EKC patients may complain about influenza-like symptoms, including fever, malaise, respiratory symptoms, nausea, vomiting, diarrhea, and myalgia.[genome.jp]
  • 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]
  • Family of adenoviruses contain different serotypes that can also cause pharyngoconjunctival fever, non-specific sporadic follicular conjunctivitis and chronic papillary conjunctivitis.[aimu.us]
  • 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]
Camping
  • In the western world, EKC strikes predominantly in selected environments: industry eye clinics, emergency rooms, nursing homes, schools, camps, and child-care centers. The virus is often found on the hands of people with active EKC.[medical-dictionary.thefreedictionary.com]
  • Bureau of aeronautics Canada CDRC Chicago color vision corneal dark adaptation Division 16 dolph Field DSRE-ARL effect Engng foreign bodies FPRC goggles home security illumination industrial injuries January Journal June Klin light Lond Luckiesh Lulworth Camp[books.google.com]
  • EKC epidemics usually take place in closed institutions like schools, camps, nursing homes, hospitals or places of work.[aimu.us]
  • Zweighaft, RM, Hierholzer, JC, Bryan, JA, Epidemic keratoconjunctivitis at a Vietnamese refugee camp in Florida. Am J Epidemiol 1977 ; 106 : 399 – 407. 23. Bietti, GB, Bruna, F, Epidemic keratoconjunctivitis in Italy.[cambridge.org]
Constitutional Symptom
  • 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]
Vietnamese
  • Zweighaft, RM, Hierholzer, JC, Bryan, JA, Epidemic keratoconjunctivitis at a Vietnamese refugee camp in Florida. Am J Epidemiol 1977 ; 106 : 399 – 407. 23. Bietti, GB, Bruna, F, Epidemic keratoconjunctivitis in Italy.[cambridge.org]
Sputum
  • She had a common cold with cough and sputum a week earlier followed by red eyes and watery discharge. Some of her kindergarten schoolmates also had red eyes during the same period.[dovepress.com]
Hematochezia
  • Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself[nejm.org]
Red Eye
  • The prompt use of patient isolation, identification of nonadenoviral red eyes, and symptomatic treatment without steroids, antiviral, or antibiotic medication is recommended in cases of epidemic keratoconjunctivitis.[ncbi.nlm.nih.gov]
  • eye room’ may be created to separate out red eye patients from other patients. – Patient and their family members should be educated about the features of the disease.[aimu.us]
  • Have you recently had a cold or have you been exposed to someone with a red eye? You may have epidemic keratoconjunctivitis (EKC). EKC infections are frequent and classic causes of viral conjunctivitis.[your-eye-sight.org]
  • She had a common cold with cough and sputum a week earlier followed by red eyes and watery discharge. Some of her kindergarten schoolmates also had red eyes during the same period.[dovepress.com]
  • Hx of recent URI or contact with someone with red eye; generally starts with one eye and a few days later can involve fellow eye b. palpebral conjunctival follicles, watery mucus discharge, eyelid sticking, tearing, may have pseudomembrane / membrane,[brainscape.com]
Excessive Tearing
  • 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]
  • 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]
  • tearing) (Fig. 1-2) Foreign body sensation Blurred vision/loss of 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[eyewiki.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]
Periorbital Edema
  • Physical examination is an equally important part of the workup, during which eyelid and periorbital edema are observed, in addition to conjunctival hyperemia.[symptoma.com]

Workup

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].

Treatment

  • 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]
  • Ophthalmologic treatments, including active occlusion therapy, should also be pursued.[ncbi.nlm.nih.gov]
  • CONCLUSION: The first priority in the treatment of patients with definite or suspected EKC is the rigorous application of hygienic measures in medical facilities, particularly because there is still no effective drug treatment for this disease.[ncbi.nlm.nih.gov]
  • 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 mean (standard deviation) time elapsed before treatment was 2.1 (1.46) days. The recovery rate within a week of treatment was 77% (95% confidence interval, 65.1-85.8). Twenty-eight participants (45.9%) recovered within a week after the onset.[ncbi.nlm.nih.gov]

Prognosis

  • 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]
  • […] 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]
  • […] 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]
  • Prognosis: Most cases of EKC are acute, benign and self-limiting. Infection usually resolves spontaneously within 2-3 weeks. Sub-epithelial infiltrates may last for months together and may decrease vision if visual axis is involved.[aimu.us]
  • All the patients recovered quickly after treating for their symptoms, and the prognosis was good. No severe cases associated with this outbreak occurred. Isolation and infection control measures were taken to prevent the spread of disease.[journals.plos.org]

Etiology

  • Abstract Following a definition of epidemic keratoconjunctivitis (EKC) and the etiologic agent responsible, a brief history of the disorder dating back to 1889 is given.[ncbi.nlm.nih.gov]
  • 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]
  • However, the nucleotide sequence of the fiber gene was identical to that of the HAdV-8 prototype strain. 22 We propose that this virus is a new hexon-chimeric intermediate HAdV-22,37/H8, and may be an etiological agent of EKC.[ncbi.nlm.nih.gov]
  • METHODS: Isolation of the etiologic agent was achieved using cultured African green monkey kidney epithelial cells (VERO).[ncbi.nlm.nih.gov]
  • Rapid antigen detection and culture confirmed adenovirus type 37 as the etiologic agent.[ncbi.nlm.nih.gov]

Epidemiology

  • 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]
  • Taking HAdV-54 into account, we re-determined HAdV type in EKC samples to determine its epidemiology in Japan, and examined the virological features of HAdV-54.[ncbi.nlm.nih.gov]
  • An outbreak within our institute caused by Ad8 from a disseminated source was characterized by molecular and epidemiological studies.[molvis.org]
  • Molecular epidemiology of adenoviral keratoconjunctivitis in Saudi Arabia. Mol Vis. 2010;16:2132–2136. 2. Gröndahl B, Puppe W, Hoppe A, Kühne I, Weigl JA, Schmitt HJ.[dovepress.com]
Sex distribution
Age distribution

Pathophysiology

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

Prevention

  • […] 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]
  • , People's Republic of China. 4 National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People's Republic of China.[ncbi.nlm.nih.gov]
  • Initial efforts to prevent nosocomial transmission were unsuccessful.[ncbi.nlm.nih.gov]
  • Recognition of conjunctivitis as an appropriate reason for restricting movement of an infected resident may have prevented extensive viral transmission in this outbreak.[ncbi.nlm.nih.gov]
  • KEYWORDS: Adenovirus; Best practices ophthalmology; Conjunctivitis; Nosocomial eye infections; Prevention of EKC; Sharing eyedrops[ncbi.nlm.nih.gov]

References

Article

  1. Kimura R, Migita H, Kadonosono K, Uchio E. Is it possible to detect the presence of adenovirus in conjunctiva before the onset of conjunctivitis? Acta Ophthalmol. 2009 Feb;87(1):44-47.
  2. Meyer-Rüsenberg B, Loderstädt U, Richard G, Kaulfers P-M, Gesser C. Epidemic Keratoconjunctivitis: The Current Situation and Recommendations for Prevention and Treatment. Dtsch Arztebl Int. 2011;108(27):475-480.
  3. Viney KA, Kehoe PJ, Doyle B, et al. An outbreak of epidemic keratoconjunctivitis in a regional ophthalmology clinic in New South Wales. Epidemiol Infect. 2008;136(9):1197-1206.
  4. Lee Y-C, Chen N, Huang I-T, et al. Human adenovirus type 8 epidemic keratoconjunctivitis with large corneal epithelial full-layer detachment: an endemic outbreak with uncommon manifestations. Clin Ophthalmol. 2015;9:953-957.
  5. Pihos MA. Epidemic keratoconjunctivitis: A review of current concepts in management. J Optom. 2013;6(2):69-74.
  6. Melendez CP, Florentino MM, Martinez IL, Mejia Lopez H. Outbreak of epidemic keratoconjunctivitis caused by adenovirus in medical residents. Mol Vis. 2009;15:557-562.
  7. Adhikary AK, Numaga J, Kaburaki T, et al. Rapid detection and typing of oculopathogenic strain of subgenus D adenoviruses by fiber-based PCR and restriction enzyme analysis. Invest Ophthalmol Vis Sci. 2001;42:2010–2015.
  8. Elnifro EM, Cooper RJ, Klapper PE, Yeo AC, Tullo AB. Multiplex polymerase chain reaction for diagnosis of viral and chlamydial keratoconjunctivitis. Invest Ophthalmol Vis Sci. 2000;41:1818–22

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Last updated: 2019-06-28 09:47