Hemorrhagic hypopyon
Hyphema is a commonly reported presentation of herpes uveitis. Whereas hemorrhagic hypopyon is rarely reported secondary to herpes uveitis. However, that wasn’t the case for a 62-year-old Japanese woman with rheumatoid arthritis and HSV uveitis.
H/O Primary RA and Sjogren Syndrome
The 62-year-old was referred for bilateral dry eyes. The Schirmer’s test result was 0 mm for both eyes. She had been diagnosed of primary rheumatoid arthritis and secondary Sjogren syndrome four years ago.
Her CT scans were normal during her first diagnosis of RA. Prior to her dry eyes’ referral, her previous hospital found CRP and LDH levels to be raised significantly, which led to the suspicion of any underlying malignancy. Lung opacities were found in the CT scan.
While she was being treated for the dry eye, she presented with hemorrhagic hypopyon in the anterior chamber, with fever and photophobia, for which she had been admitted to the hospital.
Hemorrhagic hypopyon showed niveau-like hypopyon with hemorrhage. A distinct herpetic corneal lesion was also noted with fluorescein staining. No synechiae was noted. However, keratic precipitates were. HSV was identified in the right eye.
Treatment and Diagnosis
She was treated with antiviral drugs. It improved the corneal lesions and hyphema. Unfortunately, the lesion recurred after three months, which led to suspicion of an additional hypopyon including pathology.
Since there was a history of lung opacities and elevated LDH, lung biopsy was done next, which eventually diagnosed intravascular lymphoma. She was treated of lymphoma, which resolved the ocular symptoms completely and no recurrence was seen as of 1.5 years later.
The rare presentation of hemorrhagic hypopyon could have enabled the interaction of the HSV with intravascular lymphoma. The dendritic lesions, IgG assay, response to antiviral drugs indicated the involvement of HSV. Furthermore, when anti-tumor drugs resolved all ocular symptoms, the indication of lymphoma seemed to be evident.
References
Hemorrhagic hypopyon as presenting feature of intravascular lymphoma, a case report https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5657083/
