이식거부반응으로 오인할 뻔한 거대세포 바이러스 각막내피염 1예
A Case of Cytomegalovirus Corneal Endotheliitis Almost Misdiagnosed as Corneal Graft Rejection
2
조회
0
다운로드
0
인용
0
참고문헌
키워드
초록
목적: 전층 각막 이식 후 발생한 거대세포 각막내피세포염을 경험하여 이를 보고하고자 한다. 증례요약: 2013년에 수포성 각막병증으로 우안 전층 각막이식술 후 내피세포 기능 저하에 따른 이식 실패로 2014년 4월 우안 두 번째 전층각막이식술 시행 후 경과관찰 중이던 45세 남자가 수술 후 7개월째 우안의 간헐적 충혈을 호소하며 본원 외래로 내원하였다. 환자는 재각막이식 후 7개월째로 우안의 각막부종 및 산재된 각막후면 침착물, 전방에 +1 정도의 염증 소견 및 내피세포 밀도 감소를 보여 이식거부반응을 의심하였으나 임상적으로 거대세포바이러스 각막내피염을 배제할 수 없어, 확진을 위해 진단적 우안 전방천자술을 시행하였고 real time polymerase chain reaction (RT-PCR)에서 거대세포바이러스 감염이 확진되어 Gancyclovir 경정맥주사 및 점안액을 사용하여 치료하였으며 이후 임상적 소견이 호전되었고 재발 소견은 보이지 않았다. 결론: 거대세포 각막내피염은 전형적으로 동전모양의 각막 침착물 소견을 보이며 전방 천자를 통한 RT-PCR로 진단할 수 있다. 각막이식술을 시행 받은 환자의 경우 장기간의 스테로이드 사용에 따라 바이러스와 관련된 각막내피염에 대한 위험도가 증가되며, 거대세포 바이러스 각막내피염은 임상 증상 및 소견에 있어서 충혈, 시력저하, 각막 부종, 전방염증반응 등 이식편 거부반응과 유사한 점이 있으므로 동전모양 각막 후면 침착물과 같은 특징적 소견을 보이는 경우 반드시 거대세포바이러스 각막내피염을 의심해 보아야 한다.
Abstract
Purpose: To report a case of cytomegalovirus (CMV) corneal endotheliitis following penetrating keratoplasty. Case summary: A 45-year-old male with a history of re-penetrating keratoplasty due to corneal opacity and graft failure after previous penetrating keratoplasty of his right eye in April 2014, visited our clinic for intermittent injection of the right eye for several weeks (7 months postoperative). Corneal edema, diffuse keratic pigmentation and anterior chamber reaction with decreased endothelial cell density were observed in his right eye using the slit lamp examination. Seven months after keratoplasty, corneal graft rejection were determined but clinical findings showed features of CMV-related corneal endotheliitis. Under the impression of CMV corneal endotheliitis, diagnostic paracentesis was performed for CMV real time polymerase chain reaction (RT-PCR). Additionally, the patient was admitted for intravenous ganciclovir and topical ganciclovir therapy. The next day, the RT-PCR results confirmed CMV infection. After 2 weeks of intravenous ganciclovir treatment, the patient was discharged and prescribed oral ganciclovir for 1 month. A month later, the coin-shaped corneal lesion nearly disappeared. There was no evidence of complication or recurrence. Conclusions: CMV corneal endotheliitis typically presents with coin-shaped keratic pigmentation and can be confirmed with RT-PCR using aqueous humor collected from the anterior chamber. Due to the long period of systemic and topical steroid therapy, the risk of viral endotheliitis is relatively high in patients with a history of penetrating keratoplasty. Corneal graft rejection is similar to corneal endotheliitis in symptoms and clinical features such as ciliary injection, decreased visual acuity, corneal edema or anterior chamber reaction. In patients after penetrating keratoplasty, CMV RT-PCR should be considered if the clinical features suggest viral endotheliitis.
참고문헌 (19)
- Koizumi N., "Cytomegalovirus as an etiologic factor in corneal endotheliitis", Ophthalmology, 2008(115), pp.292.e3~297.e3 (2008)
- Sonoyama H., "Detection of cytomegalovirus DNA from cytomegalovirus corneal endotheliitis after penetrating keratoplasty", Cornea, 29, pp.683~685 (2010)
- Taylor-Wiedeman J., "Monocytes are a major site of persistence of human cytomegalovirus in peripheral blood mononuclear cells", J Gen Virol, 72(Pt9), pp.2059~2064 (1991)
- Slobedman B., "Impact of human cytomegalovirus latent infection on myeloid progenitor cell gene expression", J Virol, 78, pp.4054~4062 (2004)
- Nakamura T., "Characterization and distribution of bone marrow-derived cells in mouse cornea", Invest Ophthalmol Vis Sci, 46, pp.497~503 (2005)
- Holland EJ., "The risk of cytomegalovirus transmission by penetrating keratoplasty", Am J Ophthalmol, 105, pp.357~360 (1988)
- Suzuki T., "Corneal endotheliitis", Semin Ophthalmol, 23, pp.235~240 (2008)
- Kandori M., "Prevalence and features of keratitis with quantitative polymerase chain reaction positive for cytomegalovirus", Ophthalmology, 117, pp.216~222 (2010)
- utthitham K., "The high-dose, alternate-week intravitreal ganciclovir injections for cytomegalovirus retinitis in acquired immune deficiency syndrome patients on highly active antiretroviral therapy", J Med Assoc Thai, 88(Suppl 9), pp.S63~S68 (2005)
- Ausayakhun S., "Treatment of cytomegalovirus retinitis in AIDS patients with intravitreal ganciclovir", J Med Assoc Thai, 88(Suppl 9), pp.S15~S20 (2005)
- Arevalo JF., "High-dose(5000-microg)intravitreal ganciclovir combined with highly active antiretroviral therapy for cytomegalovirus retinitis in HIV-infected patients in Venezuela", Eur J Ophthalmol, 15, pp.610~618 (2005)
- Su CC., "Topical ganciclovir treatment in patients with cytomegalovirus endotheliitis receiving penetrating keratoplasty", Clin Experiment Ophthalmol, 41, pp.339~347 (2013)
- 최원석, "A Case of CMV Endotheliitis Treated with Intravitreal Ganciclovir Injection", Korean Journal of Ophthalmology, 27(2), pp.130~132 (2013), 대한안과학회
- Panda A., "Corneal graft rejection", Surv Ophthalmol, 52, pp.375~396 (2007)
- 김은철, "전층각막이식의 거부반응", 대한안과학회지, 44(2), pp.6~295 (2003), 대한안과학회
- Koizumi N., "Clinical features and management of cytomegalovirus corneal endotheliitis : analysis of 106 cases from the Japan corneal endotheliitis study", Br J Ophthalmol, 99, pp.54~58 (2015)
- Chee SP., "Cytomegalovirus-positive corneal stromal edema with keratic precipitates after penetrating keratoplasty : a case-control study", Cornea, 32, pp.1094~1098 (2013)
- Chee SP., "Clinical features of cytomegalovirus anterior uveitis in immunocompetent patients", Am J Ophthalmol, 145, pp.834~840 (2008)
- Koizumi N., "Cytomegalovirus in aqueous humor from an eye with corneal endotheliitis", Am J Ophthalmol, 141, pp.564~565 (2006)