Acute Hemorrhagic Conjunctivitis

Individuals with acute hemorrhagic conjunctivitis have abrupt onset of eye pain,
photophobia, and swelling of the eyelids.

From: Hunter's Tropical Medicine and Emerging Infectious Diseases (Tenth Edition),
2020

Related terms:

Poliomyelitis, Adenoviridae, Serotype, Conjunctivitis, Paralysis, Enterovirus, Po-

liomyelitis Virus, Enterovirus 70

View all Topics

ACUTE HEMORRHAGIC CONJUNC-

TIVITIS 077.4 (Epidemic Hemorrhagic
Conjunctivitis, Apollo 11 Disease)
Niteen S. Wairagkar MD, in Roy and Fraunfelder's Current Ocular Therapy (Sixth
Edition), 2008

ETIOLOGY
AHC is mainly caused by enterovirus-70 and coxsackie A 24 virus, though ade-
noviruses are also reported to be associated. Evolutionary analysis of EV-70 and
CA24v, using the nucleotide sequence, indicates that the two viruses branched off f
rom the prototype strain in 1984 in Taiwan. In 2002–2003 outbreaks of AHC, the
virus strains were isolated from China, which on sequencing were identified as novel,
unclassified human enteroviruses. Viruses responsible for AHC have been isolated
from infected humans only with no animal reservoir being implicated. However,
animals may play a role in maintaining the natural cycle during an interepidemic
period.

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Coxsackieviruses, Echoviruses, and
Numbered Enteroviruses
José R. Romero, John F. Modlin, in Mandell, Douglas, and Bennett's Principles and
Practice of Infectious Diseases (Eighth Edition), 2015

Epidemiology
AHC appeared to emerge as a new disease in 1969 with explosive, pandemic spread
from simultaneous foci in Ghana and Indonesia.258 The initial epidemic caused by
EV-D70 spread along the coast of West Africa and ultimately involved many countries
on the African continent by 1973, as well as England, the former Soviet Union,
Holland, France, and Yugoslavia.259,260 CV-A24 was identified as the etiology of more
than 60,000 cases of AHC in Singapore in 1970.261-263 Subsequently, both viruses
circulated in Southeast Asia and the Indian subcontinent, causing large seasonal
outbreaks.264-267 Although the geographic distribution of AHC is wide, large-scale
epidemics have occurred predominantly in crowded coastal areas of tropical coun-
tries during the hot, rainy season.268 A 2012 outbreak of CV-A24 AHC on the French
island of Mayotte, in the Indian Ocean, affected greater than 6% of the population
and spread to neighboring islands of the Union of Comoros.269,270

Outbreaks in economically developed countries and temperate climates have been

much more limited. AHC in the West has been mostly confined to seasonal out-
breaks in Central America and the Caribbean. The disease did not appear in the
United States until September 1981, when EV-D70 conjunctivitis was first reported
in Key West, Florida. Within weeks, about 2500 cases occurred, largely among
disadvantaged persons living in Miami.271 With the exception of a few imported
cases, AHC activity has not since been noted in the United States.272 CV-A24 AHC
cases first appeared in the Western Hemisphere in Trinidad, Jamaica, St. Croix,
Panama, and Mexico in 1986.273 Two outbreaks in Cuba in 2008 and 2009 resulted
in more than 72,000 cases.274

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Ocular Disease
Edward T. Ryan, Marlene Durand, in Tropical Infectious Diseases (Third Edition),
2011

Acute Hemorrhagic Conjunctivitis

Acute hemorrhagic conjunctivitis (AHC) may be caused by adenoviruses, but two
enteroviruses, enterovirus 70 and coxsackie A24 variant, are the major causes. AHC,
first recognized as a clinical entity in Ghana in 1969, was caused by enterovirus
70; a worldwide pandemic ensued. Epidemics of AHC due to coxsackie A24 variant
have been reported since 2000 in Spain, Pakistan, Singapore, India, Korea, and
China. The 2007 epidemic in Guangdong, China, involved 200 000 people.6 Viruses
are spread by hand-to-hand and fomite-to-hand transfers. Respiratory spread may
occur. The incubation period for illness is only 1–2 days. Presentation is one of
acute conjunctivitis with eyelid edema and tearing. Affected persons often have
conjunctival hemorrhages, usually bulbar. Hemorrhagic involvement may be either
petechial or involve the entire conjunctiva (Fig. 135.2). Preauricular lymphadenopa-
thy is common. The syndrome is usually short in duration, with resolution beginning
within 2–4 days of onset, and with no long-term ocular sequelae.

Diagnosis of AHC is one of clinical recognition (usually during an epidemic), con-

firmed by viral culture, neutralization assay, or serology assay. Molecular identificat-
ion techniques are being applied to AHC outbreaks to allow rapid diagnosis, includ-
ing a reverse transcription-polymerase chain reaction (RT-PCR) assay for detecting
enterovirus 70 and coxsackie A24 variant.6 Non-enteroviral infectious agents (Box
135.1), including pneumococci, Neisseria species, Haemophilus species, Chlamy-
dia, herpesvirus, and the poultry-associated Newcastle disease virus, also may cause
“hemorrhagic conjunctivitis.”

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Ocular Disease
EDWARD T. RYAN, MARLENE DURAND, in Tropical Infectious Diseases (Second
Edition), 2006

Acute Hemorrhagic Conjunctivitis

Acute hemorrhagic conjunctivitis was first recognized as a clinical entity in Africa in
1969. The entity is highly contagious, and a pandemic ensued.12 Enterovirus 70 and
coxsackievirus 24 have been established as major etiologic agents.12,13 The viruses
are spread by hand-to-hand and fomite-to-hand transfer. Respiratory spread may
occur. The illness has an incubation period of only 1 to 2 days. Presentation is one
of acute conjunctivitis with eyelid edema and lacrimation. Ten percent to 70% of
affected persons have some conjunctival hemorrhages, usually bulbar.12 Hemor-
rhagic involvement may be either petechial or involve the entire conjunctiva (Plate
129-1).12 Mild follicular inflammatory changes can be present. Mild, self-resolving,
punctate, epithelial keratitis can occur in a small minority of patients.12 Preauricular
lymphadenopathy is frequent, and mild iritis has been reported. The syndrome is
usually short in duration, with resolution beginning within 2 to 4 days of onset and
continuing for 1 to 2 weeks. Mild systemic manifestations may include headache,
pharyngitis, and coryza in a minority of patients. There are usually no long-term
ocular sequelae. Enterovirus-70 acute hemorrhagic conjunctivitis, however, is asso-
ciated with the subsequent development of polio-like radiculomyelitis.13

The neurologic syndrome often presents with lancinating pain, fever, and malaise.
The radiculomyelitis occurs 2 to 60 days after the onset of the conjunctivitis and
most often presents acutely.12 Involvement results in flaccid weakness and paralysis
that is asymmetrical and areflexic.12,13 Pleocytosis of the cerebral spinal fluid is
present. Cranial nerves can be affected. Extraocular palsies can result. The polio-like
syndrome can resolve over months but often results in permanent deficits.12 By
analogy to what is observed in clinical poliomyelitis, the neurologic syndrome has
a predilection to occur in limbs that have received an intramuscular injection.14
Intramuscular injections should therefore be avoided in the treatment of patients
with acute hemorrhagic conjunctivitis.

Diagnosis of acute hemorrhagic conjunctivitis is one of clinical recognition (usually

during an epidemic). Viral cultures or serologic assays can be performed. Systemic
antibody responses are rarely prominent. It should be recalled that “hemorrhagic
conjunctivitis” has been associated with a number of nonenteroviral infectious
agents (Box 129-1), including pneumococci, Neisseria species, Haemophilus species,
chlamydia, herpesvirus, and the poultry-associated Newcastle disease virus. Treat-
ment of acute hemorrhagic conjunctivitis associated with enterovirus-7 and cox-
sackievirus-24 is symptomatic. Strict handwashing procedures and sterilization of
equipment should be performed.

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Enteroviruses and Parechoviruses

Kevin Messacar, ... Mark J. Abzug, in Principles and Practice of Pediatric Infectious
Diseases (Fifth Edition), 2018

Ophthalmic Infections
Acute hemorrhagic conjunctivitis is a highly contagious infection characterized
by eye pain, eyelid swelling, and subconjunctival hemorrhage (see Fig. 236.2D).
Widespread epidemics of acute hemorrhagic conjunctivitis have occurred in many
parts of the world, particularly in the tropics. Two enterovirus serotypes have been
responsible for almost all cases. Enterovirus D70 was the cause of the original
pandemic in 1969 that spread globally during the early 1970s.94 Since 1970, the
epidemiology of disease caused by a variant of coxsackievirus A24 has intertwined
with that of enterovirus D70.95 Both viruses have caused epidemics throughout
Southeast Asia and the Indian subcontinent. Disease in the West has been confined
to seasonal outbreaks in the Caribbean, Central America, and southern Florida.96

Acute hemorrhagic conjunctivitis is transmitted directly from person to person by

fingers and fomites. Both enterovirus D70 and coxsackievirus A24 are readily isolated
from tears, but only infrequently from other sites. Contagion is favored by crowding
and poor sanitation; reuse of water for bathing and sharing of towels contribute
to the spread of infection. After an incubation period of 1 to 2 days, symptoms
of ocular pain, photophobia, watery discharge, and swelling of the eyelids appear
abruptly. Fever and headache occur in 20% of cases. The distinctive physical finding
is subconjunctival hemorrhage, found in 70% to 90% of enterovirus D70 cases but
in fewer coxsackievirus A24 cases. Conjunctival edema and follicle formation, punc-
tate epithelial keratitis, and preauricular lymphadenopathy are present commonly.
Symptoms and signs peak on the first day of illness and resolve within a few days
without residual eye complications. Unusual cases of concomitant motor paralysis
have been reported during some enterovirus D70 outbreaks.

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Conjunctivitis Beyond the Neonatal Pe-

riod
Douglas R. Fredrick, in Principles and Practice of Pediatric Infectious Diseases (Fifth
Edition), 2018

Picornaviruses.
Acute hemorrhagic conjunctivitis is a highly contagious illness usually caused by
the picornaviruses, especially enterovirus 70 and coxsackievirus A24. Infection is
characterized by the sudden onset of bilateral conjunctivitis associated with profuse
watery discharge, lid edema, and fine, punctate epithelial keratitis.34–36 A prominent
distinguishing feature is the presence of subconjunctival hemorrhage, which can
be pinpoint or confluent. The disease lasts for 3 to 5 days and resolves without
adverse ocular sequelae. However, this pandemic infection can be accompanied
by neurologic involvement, in particular radiculomyelitis with extremity weakness,
unilateral facial nerve palsy, or other cranial neuropathies.37,38
 > Read full chapter

Viral Infections With Cutaneous Le-

sions
William J. Moss, ... William J. Moss, in Hunter's Tropical Medicine and Emerging
Infectious Diseases (Tenth Edition), 2020

Epidemiology
Acute hemorrhagic conjunctivitis is primarily caused by enterovirus 70 and a variant
of coxsackievirus A24; however, other enteroviruses, including echoviruses 7 and
11, coxsackieviruses B1 and B2, and several adenoviruses, can also cause acute
hemorrhagic conjunctivitis, sporadic conjunctivitis, and keratoconjunctivitis. The
first pandemic of hemorrhagic conjunctivitis was identified in Ghana in 1969 with
subsequent spread to other countries in Africa and Southeast Asia, India, Japan,
and England between 1969 and 1971, affecting millions of people.4 Enteroviruses
capable of causing hemorrhagic conjunctivitis are highly transmissible, particularly
in densely populated areas in the tropics, where good hygiene is not easy, and are
spread either directly through ocular and respiratory secretions or indirectly through
contaminated fomites (inanimate objects such as toys). Epidemics of hemorrhagic
conjunctivitis can be explosive, with up to 100% of household members and 15%
of the population ultimately infected. Outbreaks can be seasonal, particularly in
the Western Hemisphere. Individuals of both sexes and all ages are susceptible,
although adolescents and young adults are most commonly infected.5

HFMD is most commonly caused by coxsackievirus A16 and enterovirus 71. Cox-
sackievirus A6 and coxsackievirus A10 have recently caused sporadic cases and
outbreaks of HFMD, particularly in Southeast Asia and Europe.2 Other enterovirus-
es associated with HFMD include coxsackieviruses A4–A7, A9, A24, and B2–B5;
echoviruses 1, 4, 11, and 18; and enterovirus 18. HFMD was first described during an
outbreak in 19581 and has been reported in North and South America, Europe, and
Asia. However, since the 1990s, enterovirus 71–associated outbreaks have occurred
most frequently in Taiwan, Singapore, Malaysia, China, Vietnam, and Australia6 (see
Chapter 38.2).

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