AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

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• Differentials
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• Medication
• Follow-up
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Background

Acute hemorrhagic conjunctivitis (AHC) was first described in 1969. Since the first reports from Ghana, the infection has been described in numerous other countries, including China, India, Egypt, Cuba, Singapore, and Japan. An epidemic involving more than 200,000 people was reported as occurring in Brazil in 2006. Serologic studies have been useful in showing the presence of neutralizing antibodies to Coxsackie group A24 (CA24) and enterovirus E70 (EV70) strains as the causative agent.

No treatment is available. Management consists of symptomatic treatment, while waiting for the disease to run its 5- to 7-day course. AHC almost always resolves without sequelae. Corneal microbial superinfection has been reported after treatment of topical steroids and requires appropriate antimicrobial therapy.

Rarely, neurological sequelae have been noted. A poliolike paralysis has been reported in 1 case per 10,000. Also, human enteroviral infection is recognized as a major cause of aseptic meningitis in children.

Pathophysiology

AHC is characterized by conjunctival congestion, vascular dilatation, and onset of edema. Viral infections usually elicit a mononuclear cell response. In AHC, a prominent hemorrhagic component soon appears that is characteristic of this infection.

Frequency

United States

Prevalence of AHC is lower in the United States than in developing countries. Because of its occurrence in epidemics and contagious nature, estimates of the incidence of the disease in a given population have been difficult. The disease has been reported most often in the southwestern areas of the country.

International

Epidemics of AHC are most common in developing countries. Incidence has been estimated as high as one half of the population in endemic areas. The study of the seroepidemiology of AHC during an epidemic in 1983 showed neutralizing antibody of 19% to CA24 and 66.6% to EV70. Prevalence is not influenced with regard to sex or race, but children aged 10-14 years are at highest risk.

Mortality/Morbidity

The presentation of AHC can be dramatic. Findings include swollen lids; conjunctival follicles; chemosis; and, depending on the stage at which the patient is seen initially, subconjunctival hemorrhages, which can range from petechiae to large areas of conjunctival involvement. The cornea can exhibit superficial epithelial changes.

The symptoms are pain and irritation, and the lids and periocular tissues present with marked inflammation.

• Some investigators speculate that epidemics can begin when group immunity falls below a safe level. A study of change of neutralizing antibody with time was described after the 1984 epidemic of AHC in Sapporo, Japan.
• It was found that the level of EV70 neutralizing antibody decreased steadily during the first 2 years after infection and that by 7 years, 92% of the population studied had steadily decreasing titers to the point that resistance to reinfection probably was lost.

Race

AHC has been noted throughout the tropical regions of the world without regard to race. It has been the cause of worldwide pandemics. Outbreaks have been described in India, Ghana, and throughout equatorial Africa, Taiwan, China, and Cuba, as well as the southernmost portions of the United States. It also has been reported in Pakistan, Thailand, and the Middle East. No racial or ethnic predilection exists for AHC.

Sex

AHC is found in those infected by the causative virus without regard to sex. As noted before, children aged 10-14 years have been found to have the highest rate of positive neutralizing antibodies to CA24 and EV70.

Age

Epidemic hemorrhagic conjunctivitis is prevalent in all age groups, with the highest predilection for those in their early teenaged years.

CLINICAL

Section 3 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
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History

AHC is a rapidly progressive and contagious viral infection. It is characterized by the rapid onset of a painful conjunctivitis. Beginning with conjunctival follicles, the infection rapidly develops petechiae, which soon coalesce into large subconjunctival hemorrhages. The cornea may exhibit a fine superficial punctate stain.

Physical

• AHC begins with an initial period of catarrhal inflammation. The presentation becomes more dramatic with the appearance of conjunctival petechiae. These conjunctival petechiae coalesce to form subconjunctival hemorrhages. These are associated with a painful, rapidly progressive follicular conjunctivitis. The lids often become swollen and indurated. The infection resolves within 5-7 days during which the symptoms of pain and irritation are present.
• Punctate corneal epithelial defects have been noted and subepithelial corneal opacities have been described. Microbial corneal superinfection has occurred in cases receiving topical steroids. The infection resolves within 5-7 days without treatment. Sequelae in uncomplicated AHC are rare.
• The most common manifestation of enteroviral infection is a low-grade fever of unknown etiology in infants. While concerned mainly with conjunctivitis here, it should be noted that numerous organ systems can be involved. They range from myocardial to CNS involvement and also can include the respiratory system and the skin.

Causes

The viruses in the family Picornaviridae (picornaviruses) cause AHC. Specifically, CA24 and EV70 have been linked as the causative agents of this disease. The results from polymerase chain reaction (PCR) testing have been positive for CA24 and EV70, and neutralizing antibodies to CA24 and EV70 have been shown to be present in patients with AHC. Indeed, Park and colleagues have reported on a rapid identification method to determine the causative agents of AHC. This method uses PCR analysis from conjunctival swab specimens obtained from patients with AHC.

DIFFERENTIALS

Section 4 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
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WORKUP

Section 5 of 11  

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• Workup
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• Medication
• Follow-up
• Miscellaneous
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Lab Studies

• The rapid course and benign outcome of AHC, as well as the difficulty of performing rapid viral studies, make laboratory testing impractical in the clinical setting. More rapid diagnostic tests have been developed and continue to be improved. Neutralizing assays with standardized antisera have been used with good results. These are being supplanted by PCR methods, which reduce the time needed for viral typing. These methods involve amplification of the viral nucleotide sequences and their comparison to the sequences of the 66 known serotypes of human enterovirus.
• More specifically, PCR is an in vitro test, which can be used to diagnose AHC by producing large amounts of specific DNA or RNA from the infectious agent. The procedure begins with small amounts of nucleotide sequences. These sequences are called primers. The primers are obtained by denaturation of the viral DNA and then bonding the primers to their complimentary sequences. Enzymatic synthesis using DNA polymerase is used to produce larger quantities of these primers, which can be identified.
• While reliance on virus culture methods persists, rapid identification by molecular serotyping has been evaluated by Park and colleagues in an outbreak in South Korea in 2005.

Other Tests

• Culture and sensitivity studies should be obtained in all cases of corneal superinfection and appropriate antibiotics given.

Histologic Findings

The initial response to the viral infection in AHC is a mononuclear cell inflammatory response. A watery intercellular exudate is present, which is replaced by subconjunctival blood as the infection progresses.

TREATMENT

Section 6 of 11  

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Medical Care

Currently, no treatment is available for AHC. AHC usually exhibits a self-limited course. Though rare sequelae, such as radiculomyelitis, have been reported, the infection usually has no complications. Treatment with topical steroids should be avoided because of reported microbial superinfection of the cornea.

Consultations

A consultation would be appropriate in AHC only if the patient develops enteroviral infection in other organ systems. In that case, a second opinion would be of benefit depending on the nature of the systemic involvement.

MEDICATION

Section 7 of 11  

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Symptomatic treatment to make the patient as comfortable as possible is recommended. In the laboratory, benzimidazole agents have been shown to inhibit viral cultures in vitro, but this has not been tested clinically.

FOLLOW-UP

Section 8 of 11  

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Further Inpatient Care

• AHC usually is treated in an outpatient setting since no medical treatment is available. After a 24- to 72-hour period of incubation the infection runs its relatively short but uncomfortable course.
• While the general ophthalmologist most often encounters AHC, one must be aware that it is caused by members of a group of viruses causing a wide variety of conditions. Enteroviruses most often cause a benign fever. However, they also can include manifestations of neurologic, cardiac, respiratory, and dermatologic diseases. An unusual course should elicit greater than usual attention. In rare cases, consultation could be indicated with a pediatrician or pediatric subspecialist.

Further Outpatient Care

• Outpatient care of AHC consists of careful follow-up exams to ensure that no complications occur and that the infection runs a benign, self-limited course. Patient education is indicated to avoid spread of this highly contagious infection. Shedding of the viruses occurs without evidence of infection. Spread can occur between mother and child, and rates of infection typically are highest where hygiene is deficient.

Deterrence/Prevention

• Avoidance of infectious contact is the most effective way of deterring the spread of AHC. Patient education should include counseling and treatment. Humans are the sole host for the enteroviruses. The virus spreads easily through fecal-oral channels. Hygiene, education, and avoidance are the most effective preventive measures available.

Complications

• The use of topical steroids in cases of AHC was found to be a significant cause of microbial superinfection of the cornea. Neurologic sequelae of AHC have been described, but they are seen only in 1 case per 10,000 infections.

Prognosis

• This infection runs a rapid, self-limited course with good visual prognosis. Neutralizing antibodies are present for several years and confer a degree of resistance and immunity.

Patient Education

• Patient information is important in AHC to help ease fears and prevent undue alarm. The contagious nature, yet essentially benign outcome, should be emphasized, with a view toward preventing spread of the infection. Acceptance of the fact that the infection must run its course can be encouraged in the absence of an effective treatment modality.
• With the discovery and availability of new antiviral medications in the future, new treatments will become available in the future.
• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Pinkeye and Subconjunctival Hemorrhage (Bleeding in Eye).

MISCELLANEOUS

Section 9 of 11  

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Medical/Legal Pitfalls

• The practitioner should be vigilant with regard to any complications in this essentially benign condition. Be aware that rare but consequential sequelae can occur. For this reason, it is wise to schedule a final examination after the infection has subsided and to check for any residual effects.

MULTIMEDIA

Section 10 of 11  

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• Follow-up
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• Multimedia
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Media file 1:  Secondary corneal ulcer in case of acute hemorrhagic conjunctivitis treated with steroids.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

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• Aoki K, Sawada H. Long-term observation of neutralization antibody after enterovirus 70 infection. Jpn J Ophthalmol. 1992;36(4):465-8. [Medline].
• Goh KT, Ooi PL, Miyamura K. Acute haemorrhagic conjunctivitis: seroepidemiology of coxsackievirus A24 variant and enterovirus 70 in Singapore. J Med Virol. Jul 1990;31(3):245-7. [Medline].
• Moura FE, Ribeiro DC, Gurgel N. Acute hemorrhagic conjunctivitis outbreak in the city of Fortaleza, Northeast Brazil. Br J Ophthalmol. Jun 29 2006;[Medline].
• Nigrovic LE, Chiang VW. Cost analysis of enteroviral polymerase chain reaction in infants with fever and cerebrospinal fluid pleocytosis. Arch Pediatr Adolesc Med. Aug 2000;154(8):817-21. [Medline].
• Oberste MS, Maher K, Kilpatrick DR. Typing of human enteroviruses by partial sequencing of VP1. J Clin Microbiol. May 1999;37(5):1288-93. [Medline].
• Park SW, Lee CS, Jang HC. Rapid identification of the coxsackievirus A24 variant by molecular serotyping in an outbreak of acute hemorrhagic conjunctivitis. J Clin Microbiol. Mar 2005;43(3):1069-71. [Medline].
• Peter G, ed. Report on the committee of infectious diseases. In: Red Book. 24th ed. 1997:198-199.
• Rubenstein JB. Disorders of the conjunctiva and limbus. In: Yanoff MA, Duker JS, eds. Ophthalmology. Mosby;1995:5.1.5.
• Spencer WH, Zimmerman LE. Conjunctiva. In: Spencer WH, ed. Ophthalmic Pathology. Vol 1. 1985:130-131.
• Spencer WH, ed. Ophthalmic Pathology. Vol 1. 1985:128-131.
• Vajpayee RB, Sharma N, Chand M. Corneal superinfection in acute hemorrhagic conjunctivitis. Cornea. Nov 1998;17(6):614-7. [Medline].
• Wright PW, Strauss GH, Langford MP. Acute hemorrhagic conjunctivitis. Am Fam Physician. Jan 1992;45(1):173-8. [Medline].

Article Last Updated: Aug 22, 2006