Bilateral Herpes Simplex Keratitis Presenting as Peripheral Ulcerative Keratitis

Purpose: To report a case of bilateral Herpes simplex keratitis (HSK) masquerading as peripheral ulcerative keratitis (PUK). Methods: A case of a 47-year-old female complaining of painful red eyes with a history of arthritis and anterior uveitis attacks with positive antinuclear antibodies (ANA). Biomicroscopy revealed PUK, stromal infiltrations and bilateral central corneal epithelial erosions. Slit-lamp examination disclosed +3 anterior chamber cells in both eyes. Results: Blood testing was positive for ANA. Herpes simplex virus (HSV) antigen was identified in both eyes using polymerase chain reaction (PCR). The management included topical prednisolone and acyclovir, as well as systemic valacyclovir. Improvement of epithelial corneal defects, PUK, and visual acuity was achieved gradually during the follow-up period. Conclusions: Bilateral herpetic keratitis presenting as PUK is an extremely rare manifestation of herpetic disease. PUK can pose a diagnostic dilemma in cases with immune system dysregulation. Excluding infectious agents is mandatory for appropriate treatment. Key Words: bilateral herpes keratitis, peripheral corneal ulcers, polymerase chain reaction, stroma infiltrations, epithelial defect