key: cord-0785539-y2p97hqa
authors: Bettach, Emmanuel; Zadok, David; Weill, Yishay; Brosh, Kobi; Hanhart, Joel
title: Bilateral anterior uveitis as a part of a multisystem inflammatory syndrome secondary to COVID‐19 infection
date: 2020-06-27
journal: J Med Virol
DOI: 10.1002/jmv.26229
sha: 38fa7d687d85fc7d866f26ef1d342c074b01b723
doc_id: 785539
cord_uid: y2p97hqa

During the ongoing COVID‐19 pandemic, there is a global concern about patients presenting with inflammatory syndrome with variable clinical features. Colanfrancesco et al. described COVID‐19 systemic inflammatory reaction that are characterized by a life‐threatening hyper‐inflammation sustained by a cytokines storm which eventually leads to multi‐organ failure. This article is protected by copyright. All rights reserved.

During the ongoing COVID-19 pandemic, there is a global concern about patients presenting with inflammatory syndrome with variable clinical features.

Colanfrancesco et al. 1 described COVID-19 systemic inflammatory reaction that are characterized by a life-threatening hyper-inflammation sustained by a cytokines storm which eventually leads to multi-organ failure.

Previous studies observed an ongoing outbreak of Kawasaki-like multisystem inflammatory syndrome among children and adolescents that might be related to SARS-CoV-2 with a 30-fold increased incidence reported in Italy. 2, 3 The extent of these inflammatory reactions is yet not fully understood and to the best of our knowledge, no ocular manifestation has been reported in adults as a part of these inflammatory conditions related to SARS-CoV-2.

A 54-year old female, with no significant past medical history, was admitted to the intensive care unit (ICU) with fever, septic shock, gastrointestinal symptoms, heart failure, and a skin rash. During her hospitalization a comprehensive workup was studies showed that conjunctivitis could be a manifestation of COVID-19 and may be associated with a more severe form of the disease. 4, 5 Coronaviruses are known to cause various ocular infections in animals such as conjunctivitis, anterior uveitis, retinitis, and optic neuritis. 6 Cheema et al. 7 presented recently a case of COVID-19 that presented initially to ophthalmology clinic with keratoconjunctivitis with small pseudodendrite and small subepithelial infiltrates in the cornea.

Foon NG et al. 8 recently described pediatric inflammatory multisystem syndrome in 3 teenagers with serologically-confirmed SARS-CoV-2 infection and a clinical presentation of fever, conjunctivitis, rash, gastrointestinal symptoms and circulatory shock. Another group in Italy described a case of a clinically well 9 years-old patient with laboratory parameters strongly suggestive of a multiorgan involvement due to infection or inflammation with serologically-confirmed SARS-CoV-2 infection. 9

The multisystem inflammatory syndrome that has developed the patient seems to be clinically similar to a Kawasaki-like disease which is known in pediatric population.

Shiari et al. 10 reported 36.1% of acute anterior uveitis in children with Kawasaki disease and found an association between uveitis and coronary artery dilatation.

Another study found that the presence of anterior uveitis is helpful in the early diagnosis and treatment of incomplete Kawasaki disease and can be used as an additional diagnostic tool. 11 We postulate that the anterior uveitis was secondary to COVID-19 infection. It is important to report that the patient denied medical history of chronic autoimmune and inflammatory conditions. We cannot formally rule out other etiologies, particularly herpetic, since paracentesis was not performed. Regarding COVID-19, due to the limitation of ancillary resources when the pandemic was raging, we could not perform a swab PCR of the tears, yet it would probably have returned negative since the PCR of the nasopharyngeal swab was found to be negative 3 times.

We present this case of ocular involvement in a systemic inflammatory syndrome secondary to COVID-19 infection to emphasize the importance for the health care providers to be aware of the possible inflammatory ocular manifestation during and after a COVID-19 infection. 

COVID-19 gone bad: A new character in the spectrum of the hyperferritinemic syndrome?

An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study

Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study

The possibility of COVID-19 transmission from eye to nose

Conjunctivitis and COVID-19: A meta-analysis

Can the Coronavirus Disease 2019 (COVID-19) Affect the Eyes? A Review of Coronaviruses and Ocular Implications in Humans and Animals

Keratoconjunctivitis as the initial medical presentation of the novel coronavirus disease 2019 (COVID-19)

COVID-19 Multisystem Inflammatory Syndrome in Three Teenagers with Confirmed SARS-CoV-2 Infection

A child with a severe multi-system inflammatory syndrome following an asymptomatic COVID-19 infection: a novel management for a new disease

Relationship between ocular involvement and clinical manifestations, laboratory findings, and coronary artery dilatation in Kawasaki disease

Usefulness of anterior uveitis as an additional tool for diagnosing incomplete Kawasaki disease