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Show Journal of Clinical Neuro- ophtluJlmology 11( 2): 109- 110, 1991. Tonic Pupils and Human Parvovirus ( BI9) Infection © 1991 Raven Press, Ltd., New York P. G. J. Corridan, F. R. C. S., F. C. Ophth., D. Eo Laws, F. R. C. S., FoC. Ophth., A. J. Morrell, F. R. C. S., F. C. Ophth., and P. I. Murray, Ph. D., F. R. CoS., F. C. Ophth. We document the case of a young woman with bilateral internal ophthalmoplegia and subsequently tonic ( Adie's) pupils, corneal epitheliopathy, and uveitis due to human parvovirus BI9 infection. To our knowledge, this is the first reported case of ocular complications of this virus. Key Words: Human parvovirus BI9- Internal ophthalmoplegia- Adie's pupils- Corneal epitheliopathyUveitis. From the Birmingham and Midland Eye Hospital, Birrningham, England. Address correspondence and reprint reque~ ts ~ o Mr. P. I. Murray at Academic Unit of Ophthalmology, BlTTnmgham and Midland Eye Hospital, Church Street, Birmingham 63 2NS, U. K. 109 Erythema infectiosum ( fifth disease) is a common acute exanthematous disease of childhood which occasionally affects adults. The etiological agent has been identified ( 1) as human parvovirus B19. The portal of entry is usually the respiratory tract. Typically a skin rash starts on the cheeks ( slapped cheek appearance) and later spreads to the trunk and limbs. B19 infection is usually a mild disease associated with nonspecific respiratory symptoms, the main complication being joint involvement which is self- limiting; it particularly affects adult women ( 2). Ocular complications of this virus have not been previously described. We report the case of a young adult woman who developed an internal ophthalmoplegia and subsequently tonic ( Adie's) pupils, corneal epitheliopathy, and uveitis following infection with human parvovirus B19. CASE REPORT A previously healthy 18- year- old caucasian woman developed pyrexia, erythema of the hands and face, and mild peripheral edema. She was admitted for investigation and the diagnosis of human parvovirus B19 infection was made serologically by positive anti- Bl9 IgM and IgG as measured by antibody capture radioimmunoassay ( 3). All other serologic, immunologic, and radiologic studies gave normal results. Over the next few weeks she complained of blurred vision. She denied any previous eye problems. On examination, her visual acuities were 20/ 20, Jaeger 10 in the right eye, and 20/ 15, Jaeger 10 in the left. She was able to read Jaeger 1 in each eye with a + 2.5 dioptre spherical correction. Both pupils were widely dilated and failed to respond to light or accommodation. She had bilateral mild 110 P. G. J. CORRIDAN ET AL. punctate corneal epitheliopathy, which stained with topical sodium fluorescein, and bilateral corneal anaesthesia. There was bilateral anterior uveitis associated with some ciliary injection. Large keratic precipitates were present but had an unusual distribution, occurring predominantly in the periphery of each cornea. Mild anterior vitritis was also noted in both eyes. The left optic disc appeared hyperemic, but the right disc was normal. Both retinae were normal in appearance, as was the retinal vasculature. Computerised tomography of brain and orbits, visual evoked responses to flash and pattern stimulation, electroretinograms, and Goldmann visual field testing were all normal. Her pupillary responses were unchanged 6 weeks after the onset of her ocular problems, but 3 months later light- near dissociation was present with sectorial vermiform pupillary movements. Hypersensitivity to topical methacholine 2.5% was demonstrated, confirming the diagnosis of tonic ( Aide's) pupils. Her deep tendon reflexes were normal. After 6 months, corneal hypoaesthesia was present and the corneal epitheliopathy had followed a relapsing and remitting course, responding to ocular lubricants. The uveitis gradually resolved after 3 months on topical steroid therapy. The appearance of the left optic disc returned to normal after 5 months. DISCUSSION To our knowledge, this is the first reported case of ocular complications following human parvovirus B19 infection. The finding of an aborted fetus with eye anomalies possibly related to B19 infection has previously been described ( 4), but none of the neonates or fetuses from a large prospective study of B19 infection in pregnancy had eye defects reported ( 5). Neurological complications such as encephalitis ( 6) and brachial plexus neuropathy ( 7) have been documented, and it is likely that in our case bilateral ciliary ganglionitis resulted in the pupillary abnormalities demonstrated. As the nerve fibres subserving corneal sensation also pass through the ciliary ganglion, the patient's corneal pathology probably occurred due to damage of these fibres. Uveitis is a well- recognized but infrequent complication of some viral infections ( 8,9), but it is rarely found in association with corneal and pupillary abnormalities ( 10). We feel that human parvovirus B19 should now be added to the list of infectious agents causing ocular disease. Acknowledgment: We thank Dr. M. P. Skander for assistance. REFERENCES 1. Anderson MJ, Lewis E, Kidd 1M, Hall SM, Cohen BJ. An outbreak of erythema infectiosum associated with human parvovirus infection. / Hyg ( Lond) 1984; 92: 85- 93. 2. Reid DM, Brown T, Reid TMS, Rennie JAN, Eastmond q. Human parvovirus- associated arthritis: a clinical and laboratory description. LAncet 1985; i: 422- 5. 3. Cohen BJ, Mortimer PP, Pereira MS. Diagnostic assays with monoclonal antibodies for the human serum parvoviruslike virus ( SPLV). / Hyg ( Lond) 1983; 91: 113- 30. 4. Weiland HT, Vermey- Keers C, Salimans MMM, Fleuren GJ, Verwey RA, Anderson MJ. Parvovirus B19 associated with fetal abnormality. LAncet 1987; i: 682- 3. 5. Public Health Laboratory Service Working Party on Fifth Disease. Prospechve study of human parvovirus ( B19) infection in pregnancy. Br Med / 1990; 300: 1166-- 70. 6. Balfour HH, Schiff GM, Bloom JE. Encephalitis associated with erythema infectiosum. / Pediatr 1970; 77: 133- 6. 7. Walsh KJ, Armstrong RD, Turner AM. Brachial plexus neuropathy assoaated With human parvovirus infection. Br Med / 1988; 296: 896. 8. Martenet A- C. Role of viruses in uveitis. Trans Ophthalmol Soc UK 1981; 101: 308-- 11. 9. Kelly SP, Rosenthal AR. Chickenpox chorioretinitis. Br J OphthalmoI1990; 74: 698-- 9. 10. Dubois HF, van Bijsterveld OP. Internal ophthalmoplegia, an uncommon complication of varicella a common infec-tion. Ophthalmologica 1977; 175: 263- 8. ' |
