Acute Hemorrhagic Conjunctivitis
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Acute hemorrhagic conjunctivitis (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. (See Etiology, History, and Physical Examination.)
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, Taiwan, Japan, Pakistan, Thailand, and the United States. [1, 2, 3, 4] An epidemic involving more than 200,000 people was reported as occurring in Brazil in 2006. [5] 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. [4, 6] (See Epidemiology and Workup.)
Humans are the sole host for the enteroviruses. The virus spreads easily through fecal-oral channels. The rates of AHC infection typically are highest where hygiene is deficient. (See Etiology.)
Spread can occur between mother and child.
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, having a good visual prognosis. However, corneal microbial superinfection has been reported after treatment with topical steroids and requires appropriate antimicrobial therapy. (See Treatment.)
A secondary corneal ulcer is shown below.
Rarely, neurologic sequelae have been noted in AHC. 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.
Neutralizing antibodies are present for several years and confer a degree of resistance and immunity.
Change of neutralizing antibody with time was described after the 1984 epidemic of AHC in Sapporo, Japan. A study 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.
Some investigators speculate that epidemics can begin when group immunity falls below a safe level.
The prevalence of AHC is not influenced by sex or race, but children aged 10-14 years are at highest risk. (See Epidemiology.)
See the following for more information:
Emergent Treatment of Acute Conjunctivitis
Giant Papillary Conjunctivitis
Superior Limbic Keratoconjunctivitis
The viruses in the family Picornaviridae (picornaviruses) cause acute hemorrhagic conjunctivitis (AHC). Specifically, CA24 and EV70 have been linked as the causative agents of AHC. 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.
Shedding of the viruses occurs without evidence of infection.
The prevalence of acute hemorrhagic conjunctivitis (AHC) is lower in the United States than in developing countries. Because of its occurrence in epidemics and its 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 United States.
AHC has been the cause of worldwide pandemics. Outbreaks have been described in India, Ghana, and throughout equatorial Africa, as well as in Taiwan, China, Japan, Singapore, and Cuba. It also has been reported in Pakistan, Thailand, and the Middle East. [1, 2, 3, 4]
Epidemics of AHC are most common in developing countries. Incidence has been estimated to be 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.
AHC has been noted throughout the tropical regions of the world without regard to race or ethnic background. AHC has no sex predilection.
Epidemic hemorrhagic conjunctivitis is prevalent in all age groups, but the highest predilection is for persons in their early teenaged years. Children aged 10-14 years have been found to have the highest rate of positive neutralizing antibodies to CA24 and EV70.
Recent studies in Changsa, China have assessed the efficacy of a quarantine method to help control outbreaks of AHC in schools. It was estimated that without intervention, almost all students would have become infected in 23 days. Using what the authors termed a susceptive-infective-quarantine removal (SIQR) model, the authors concluded that in the absence of definitive treatment, quarantine programs could be used to curtail AHC outbreaks at schools and reduce the number of accumulated cases. [7]
Patient education is important in acute hemorrhagic conjunctivitis (AHC) to help ease fears and to prevent undue alarm. The contagious nature, yet essentially benign outcome, of the disorder should be emphasized, with a view toward preventing the 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.
Patient education is also indicated to avoid the spread of this highly contagious infection.
For patient education information, see the Eye and Vision Center, as well as Pinkeye and Subconjunctival Hemorrhage (Bleeding in Eye).
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Cabrerizo M, Echevarria JE, Otero A, et al. Molecular characterization of a coxsackievirus A24 variant that caused an outbreak of acute haemorrhagic conjunctivitis in Spain, 2004. J Clin Virol. 2008 Nov. 43(3):323-7. [Medline].
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Jean Deschênes, MD, FRCSC Professor, Research Associate, Director, Uveitis Program, Department of Ophthalmology, McGill University Faculty of Medicine; Senior Ophthalmologist, Clinical Director, Department of Ophthalmology, Royal Victoria Hospital, Canada
Jean Deschênes, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Canadian Medical Association, Canadian Ophthalmological Society, International Ocular Inflammation Society, Quebec Medical Association
Disclosure: Nothing to disclose.
Ayman J Aljohani, MBBS Resident Physician, Department of Ophthalmology, McGill University Faculty of Medicine, Canada
Ayman J Aljohani, MBBS is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Association for Research in Vision and Ophthalmology, International Society for Eye Research
Disclosure: Nothing to disclose.
Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society
Disclosure: Nothing to disclose.
Christopher J Rapuano, MD Professor, Department of Ophthalmology, Sidney Kimmel Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Hospital
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, AAO, OMIC, Allergan; Avedro; Bio-Tissue; GSK, Novartis; Shire; Sun Ophthalmics; TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Avedro; Bio-Tissue; Shire.
Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.
Fernando H Murillo-Lopez, MD Senior Surgeon, Unidad Privada de Oftalmologia CEMES
Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.
George Plechaty, MD Clinical Assistant Professor, Department of Surgery, Division of Ophthalmology, University of Hawaii, John A Burns School of Medicine
George Plechaty, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the assistance of Ryan I Huffman, MD, with the literature review and referencing for this article.
Acute Hemorrhagic Conjunctivitis
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