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"Child`s Health" 7 (50) 2013

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Fetures of clinical course and approaches to diagnostics of inflammatory eye disease in children caused by the persistent intracellular infections

Authors: E. Yulish, L. Suchina, A. Lysenko - Donetsk National Medical University of Maxim Gorky, Donetsk, Ukraine; T. Bukhanovska - State Medical Academy of Postgraduate Education named after P. L. Shupyk, Kyiv, Ukraine

Categories: Pediatrics/Neonatology

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Introduction. The relevance of the inflammatory diseases caused by persistent intracellular infections, including Herpes simplex virus (HSV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), Toxoplasma Gondi, Chlamydia trachomatis, determined by their significant prevalence in the population, a variety of clinical symptoms, duration of the pathological process and recurrent course of diseases, high frequency of complications and resistance to therapy. In children, the pathology of the eye caused by these infections, has more severe course and worse prognosis because of the involvement into the chronic inflammatory process is not yet completely formed structures of the eye, a tendency to generalization of the process and the rapid development of complications, which lead to irreversible loss of vision.

Purpose. To investigate the clinical manifestations and approaches to diagnostics of inflammatory eye disease in children caused by caused by persistent intracellular infections.

Methods. Study of data of 90 patients with inflammatory eye diseases before the age of 18 years. Were observed: 34 patients with conjunctivitis, 10 patients with keratitis, 42 patients with uveitis and 4 –with neuritis. Children were examined by serological tests and polymerase chain reaction (PCR) methods. PCR evaluations of the conjunctival scraping were performed in patients with conjunctivitis and keratitis,  saliva and serum were collected from patients with uveitis and neuritis. Serological tests with study levels of antibody IgG, IgА, IgM were performed. After treatment during 3-4 weeks we have studied presence of pathogen DNA in the test of biological media.

 Results. Analysis of the data showed, that the leading form of inflammatory eye disease, caused by herpetic infections were anterior and posterior uveitis. Posterior uveitis was most common and was observed in 30 (71,4%±7,0%) patients and anterior uveitis in 12 patients (28,6%±7,0%).With long-term course of disease-from 3 month to 5 years, bilateral ocular involvement was observed in 19 (45,2%± 7,7%).

Of patients with uveitis, duration was chronic and recurrent  was in 18 (43%). Latent disease course was diagnosed in 29 (69%) patients. Replicative activity with detection DNA of pathogen were observed in 13 (31%) patients, including DNA of EBV were detected in 6 (14%) patients, DNA of CMV in 5 (12%) patients, DNA of HSV in 2 (4,7%) patients.

The most common etiology of posterior uveitis was CMV (35,7%), followed by toxoplasma (31%) and herpetic co-infections (26%). The leading cause of anterior uveitis were HSV and EBV infections, also herpetic (HSV, EBV) and Chlamydia trachomatis combinations.

Features of clinical course of chronic recurrent uveitis in young children caused by herpetic infections and combination with Chlamydia trachomatis and Toxoplasma gondi were: insidious onset, exudation into the vitreous with the outcome of fibrosis, development of such complications as cataract, vitreoretinal adhesions, retinal detachment. Not clear clinical symptoms in the early stages of the uveitis in children, lead to the generalization process and rapid development of severe complications and irreversible loss of vision.

Active EBV infections were detected in 4 patients with posterior uveitis. Clinical manifestations were: onset of the disease on the background of the previous respiratory disease, several minor chorioretinal foci in the center of retina. Acute cystoid serous macular edema was revealed in 2 patients with active EBV infections.

Acute duration of herpetic infections was observed in 6 patients with keratitis (60%).   DNA and antibody productions against HSV were detected in conjunctiva of 4 patients. Furthermore, conjunctiva scraping and saliva analysis were positive for EBV in 2 children and for CMV in 1 patient with keratitis.

In the investigation of DNA by PCR on the presence of Chlamydia trachomatis of 34 children with conjunctivitis, including 26 infants and 8 adolescents, the positive results was detected in 13 (38,2%) cases, of whom 10 (29,4%) newborns and 3 (8,8%) older children.

Features of clinical course of chlamydial conjunctivitis in newborns, confirmed by PCR study, were significant swelling of the mucous eyelids and purulent discharge,

chemosis, expressed exudation. In adolescents the conjunctivitis differ expressed follicular hyperplasia, as well as profuse purulent discharge and strong swelling of the eyelids mucous.

Despite the small number of children with the optic nerve disease, who were included in the study, our attention was drawn to 100% relationship of the disease with active herpetic infections. All patients had positive PCR for HSV, EBV and CMV in the saliva and high level of antibodies in serum.

Conclusion.

1. Uveitis in childhood, caused by persistent intracellular infections such as herpetic infections, chlamydia trachomatis and toxoplasma gondi, are  potentially blinding diseases, which in 43% are characterized by chronic recurrent and persistent course with insidious onset and lead to development of severe complications and irreversible loss of vision.
2. To determine the nature of the course (active or latent) and targeted treatment of the inflammatory eye diseases caused by persistent intracellular infections, recommended to perform molecular-biological analysis (PCR) of saliva and scraping of conjunctiva, as well as serological research of specific immunoglobulins.
3. The criteria for active infections are the clinical manifestation of the disease, as well as the obligatory presence of laboratory markers of replicative activity of pathogens, detection of DNA in such biomaterials as saliva and blood in patients with uveitis and neuritis, conjunctival scraping in patients with keratitis.
4. All patients with pathology of the optic nerve at baseline have to be screened for the presence of an active course of herpesvirus infections. 
                  


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