Herpes simplex virus dissemination with necrotizing hepatitis following Descemet membrane endothelial keratoplasty

• Published in: BMC infectious diseases 2023-07, Vol.23 (1), p.465-465, Article 465
• Main Authors: Azeem, Ahad, Baartman, Brandon, Conrady, Christopher D, Meier, Jeffery L, El-Herte, Rima
• Format: Article
• Language: English
• Subjects: Abdomen; Acyclovir; Aged; Anterior chamber; Antigens; Bacterial infections; Biopsy; Blood; Blood platelets; Case Report; Cerebrospinal fluid; Contact lenses; Control; Cornea; Cornea transplant; Corneal transplant infection; Corneal transplantation; Corneal Transplantation - adverse effects; Creatinine; Deoxyribonucleic acid; Descemet Membrane; Disease transmission; DNA; Emergency medical care; Endothelium; Eye; Eye diseases; Eye surgery; Failure; Fever; Foscarnet; Graft rejection; Grafting; Health aspects; Hemodialysis; Hemoglobin; Hemophagocytic lymphohistiocytosis; Hepatitis; Hepatitis A; Herpes keratitis; Herpes simplex; Herpes Simplex - diagnosis; Herpes simplex hepatitis; Herpes simplex virus; Herpes viruses; Herpesvirus 1, Human; Histiocytosis; Humans; Identification and classification; Illnesses; Infections; Infectious diseases; Lymphocytes; Lymphocytosis; Magnetic resonance imaging; Male; Membranes; Neutrophils; Organ transplant recipients; Peripheral blood; Prevention; Renal failure; Rhabdomyolysis; Risk factors; Seroconversion; Surgery; Tazobactam; Tissues; Tomography; Transplantation; Transplants; Uveitis
• ISSN: 1471-2334; 1471-2334
• DOI: 10.1186/s12879-023-08414-6

Corneal transplants are the most common type of transplant and increasing in frequency. Donor cornea tissues are a rare source of herpes simplex virus (HSV) transmission and not routinely tested for presence of HSV. Donor graft-to-recipient transmission typically causes graft failure and anterior uveitis, and extra-ocular HSV disease has not been previously reported. We present a case of HSV transmission from donor cornea tissue that nearly cost the corneal transplant recipient his life. An elderly immunocompetent man developed an acute illness 10 days after having donor corneal tissue implanted in a Descemet membrane endothelial keratoplasty (DMEK). He was found to have HSV necrotizing hepatitis per liver biopsy, trilineage cytopenia, rhabdomyolysis, acute kidney failure, altered mental status, early-stage hemophagocytic lymphohistiocytosis (HLH), and donor corneal tissue implant infection resulting in graft failure and anterior uveitis. HSV DNA was detected in cerebral spinal fluid, peripheral blood, explanted donor corneal tissue, and anterior chamber fluid (220 million HSV DNA copies per mL). HSV-1 seroconversion denoted a primary HSV infection, and the patient had no other risk factor for HSV acquisition. Early recognition of HSV dissemination prompting treatment with intravenous acyclovir, as well as a short course of HLH-directed therapy, resolved the systemic illness. Vision was restored to near normal by replacement of the infected corneal graft with new donor DMEK tissue in conjunction with intravitreal foscarnet treatment. Awareness of the potential risk of donor cornea tissue transmitting HSV and leading to life-threatening HSV disease is paramount to early diagnosis and treatment. The role of donor cornea tissue in HSV transmission and disease merits additional attention and investigation.