Bilateral anterior and intermediate uveitis associated with parvovirus B19 infection in a pediatric patient: A case report

INTRODUCTION

Parvovirus B19 (B19V) is a single-stranded DNA virus belonging to the Parvoviridae family. Seroprevalence among young adults in developed countries is estimated to be 40–60%.^1,2 The infection commonly occurs during childhood and typically manifests as erythema infectiosum, characterized by fever, facial rash, and a maculopapular eruption affecting the trunk and extremities. Arthralgia and arthritis are more frequently observed in adults, particularly women.^1,2

Although parvovirus B19 infection is generally self-limited, severe complications may occur in immuno-compromised individuals or patients with underlying hematologic disorders. Reported systemic complications include hepatitis, encephalitis, and hematologic abnormalities.^2,3

Ocular manifestations associated with parvovirus B19 infection are extremely rare. Only a small number of cases of B19V-associated uveitis have been reported in the literature. The underlying mechanism remains uncertain, with both direct viral infection and immune-mediated inflammation proposed as possible explanations.^4-9

We report a case of bilateral anterior and intermediate uveitis in a pediatric patient occurring shortly after systemic parvovirus B19 infection. This case highlights the diagnostic challenges and therapeutic considerations associated with this rare ocular manifestation.

CASE REPORT

A previously healthy 5-year-old boy presented to the emergency department with a one-week history of bilateral ocular pain and conjunctival hyperemia. These symptoms developed shortly after hospitalization for fever, bilateral arthromyalgia, and pneumonia attributed to parvovirus B19 infection. The pneumonia was treated with oral amoxicillinclavulanate due to pulmonary infiltrates suggestive of bacterial superinfection, with good systemic recovery. The patient had no family history of uveitis, inflammatory arthritis, or other autoimmune disorders.

A comprehensive laboratory work-up performed during the hospitalization excluded several infectious and inflammatory causes. Serologic testing was positive for Parvovirus B19, and negative for syphilis, herpes simplex virus types 1 and 2, Varicella-Zoster virus, Borrelia burgdorferi, Toxoplasma gondii, and Bartonella henselae. Inflammatory and autoimmune markers, including angiotensin-converting enzyme, lysozyme, Quantiferon-TB Gold, antinuclear antibodies, antineutrophil cytoplasmic antibodies, anticardiolipin antibodies, rheumatoid factor and HLA-B51, were also negative.

Ophthalmologic examination revealed a best-corrected visual acuity of 0.3 in the right eye and 0.2 in the left eye. Slit-lamp examination demonstrated bilateral conjunctival hyperemia, fine keratic precipitates, and marked anterior chamber inflammation graded as 3+ cells, with no keratitis.

Posterior synechiae and fibrin deposits were present, while the crystalline lens remained clear. Intraocular pressure was 10 mmHg in both eyes. Fundus examination was limited due to poor cooperation and media opacity from the anterior chamber inflammation.

B-scan ultrasonography revealed dense vitreous opacities in both eyes, consistent with bilateral vitritis, without evidence of retinal detachment [Figure 1].

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Figure 1: (A) Right eye, (B) left eye; Scan ultrasound showing dense vitreous opacities (white arrows) in both eyes, suggestive of bilateral hyalitis.

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Based on these findings, a diagnosis of anterior and intermediate uveitis was suspected. Treatment was initiated with intensive topical dexamethasone 0.1% eye drops in a tapering regimen (starting at ten times daily), combined with atropine 1% twice daily and tropicamide three times daily.

Despite four days of therapy, the patient’s condition worsened. Visual acuity declined to 0.1 in both eyes, new granulomatous keratic precipitates appeared, and the anterior chamber reaction persisted. Fundus examination revealed vascular tortuosity and persistent vitritis without evidence of optic disc oedema.

Because of clinical deterioration, an examination under general anesthesia was performed. Fluorescein angiography showed mild vascular tortuosity but no macular leakage, vasculitis, or papillitis. Anterior chamber fluid was obtained for microbiological analysis, and a subconjunctival injection of dexamethasone was administered [Figures 2 and 3].

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Figure 2: (A) Right eye (B) Left eye; Fundus examination performed under general anesthesia. No evidence of papillitis (black circle showing a papilla with defined borders) or retinal deposits. Note the mild bilateral vascular tortuosity (black arrows).

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Figure 3: (A) Right eye, (B) left eye; Fluorescein angiography performed under general anesthesia revealed bilateral vascular tortuosity (black asterisks) with no evidence of leakage at the macular, vascular, or optic disc level, thus excluding the presence of vasculitis or papillitis (black circle – showing a papilla with defined borders).

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Polymerase chain reaction (PCR) analysis of the anterior chamber sample detected parvovirus B19 DNA, confirming the infectious etiology of the uveitis.

Ten days after the procedure, the patient showed marked clinical improvement. Visual acuity recovered to 1.0 in both eyes, with only trace anterior chamber inflammation. Conjunctival hyperemia, keratic precipitates, and posterior synechiae had resolved completely. Follow-up evaluations were performed at 3, 6, and 12 months after the acute episode, with no evidence of recurrence or ocular sequelae, while maintaining a best-corrected visual acuity of 1.0.

DISCUSSION

Parvovirus B19–associated uveitis is rare, with only a few cases reported in the literature, as seen in Table 1.^4-9 Most previously described cases involve bilateral ocular inflammation, and several have occurred in pediatric patients.

In children presenting with bilateral uveitis, the differential diagnosis includes juvenile idiopathic arthritis–associated uveitis, viral infections, and post-infectious inflammatory syndromes. Juvenile idiopathic arthritis uveitis is typically asymptomatic and often lacks conjunctival hyperemia, whereas viral uveitis frequently presents with ocular pain and redness. In our patient, the presence of ocular discomfort, conjunctival hyperemia, and a recent viral illness raised suspicion of an infectious etiology.^4-9

Another important differential diagnosis is post-streptococcal uveitis, which usually develops following group A streptococcal pharyngitis.¹⁰ This condition is characterized by acute bilateral anterior uveitis and may be associated with fibrin or hypopyon in the anterior chamber. In the present case, negative throat culture and antistreptolysin-O titers helped exclude this possibility.

PCR detection of viral DNA in intraocular fluid was essential in confirming the diagnosis. The detection of parvovirus B19 DNA in the anterior chamber strongly supports a direct viral role in the development of intraocular inflammation.

Furthermore, given the absence of a family history of uveitis, arthritis, or cutaneous rash, together with the documented antecedent parvovirus B19 infection and the positive anterior chamber PCR for the virus, genetic testing for NOD2-associated Blau syndrome was not considered necessary in this case.

The pathophysiology of B19V-associated uveitis remains uncertain. Two main mechanisms have been proposed: direct viral infection of ocular tissues and immune-mediated post-infectious inflammation. In this patient, the absence of autoimmune antibodies and the detection of viral DNA in ocular fluid support the hypothesis of a direct infectious mechanism.^2-4

Most previously reported cases responded well to topical corticosteroid therapy. In our patient, however, inflammation progressed despite intensive topical treatment, requiring subconjunctival corticosteroid injection. This intervention resulted in rapid resolution of inflammation and full visual recovery.

This case also highlights the importance of early diagnostic evaluation in pediatric uveitis. Identification of the underlying cause allows appropriate management and may help prevent vision-threatening complications.

CONCLUSION

Parvovirus B19 infection should be considered in the differential diagnosis of pediatric patients presenting with bilateral uveitis, particularly when ocular symptoms occur shortly after systemic viral illness. PCR analysis of intraocular fluid can help confirm the diagnosis. Early recognition and appropriate management are essential to achieve favorable visual outcomes.