HSV Keratitis: Diagnostic Errors and Differential Diagnosis

There are a number of factors which make detection of ocular herpes a daunting task. We are going to cover some of them.

Conditions to consider in the differential diagnosis of HSV keratitis include the following:

Disorder groups Disorders
Corneal dystrophies
  • acute keratoconus
  • corneal degenerations
  • deep dystrophies (e.g., Fuchs' endothelial dystrophy)
Autoimmune disorders
  • Mooren’s ulcer
  • rosacea keratitis
  • keratomalacia caused by undernutrition
  • autoimmune disorders
Other infections
  • tuberculosis (phlyctenular keratoconjunctivitis)
  • acanthamoeba keratitis
  • adenovirus
Herpes associated with other infections (mixed infections)
  • herpes + tuberculosis
  • herpes + pyogenic infection (staphylococcus, streptococcus, pseudomonas aeruginosa, etc.)
  • herpes + fungi
  • herpes + acanthamoeba
  • herpes + HIV
Infections with other types of herpesviruses
  • varicella-zoster, Epstein-Barr virus, etc.

Proper differential diagnosis requires thorough history taking, virology tests, serological and bacterial tests (if needed), as well as corneal scraping and sometimes biopsy. Confocal microscopy may be a viable diagnostic technique if acanthamoeba is suspected.