Ophthalmological Features of Kyasanur Forest Disease Virus (KFDV)

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Article initiated by:

Andrew Go Lee, MD, Luke Newton, Peter W. Mortensen, MD, Subahari Raviskanthan, MBBS

All contributors:

Leo A. Kim, MD, PhD, Nagham Al-Zubidi, MD, Peter W. Mortensen, MD, Neelakshi Bhagat, MD, FACS, Razek Georges Coussa, MDCM, MPhil, MEng

Assigned editor:

Razek Georges Coussa, MDCM, MPhil, MEng, Sonali Singh MD

Review:

Assigned status Up to Date

 by Razek Georges Coussa, MDCM, MPhil, MEng on December 1, 2024.

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Disease Entity

Kyasanur Forest Disease Virus (KFDV) is a zoonotic disease caused by a single-stranded, positive-sense RNA arbovirus, that is part of the Flavivirus genus within the Flaviviridae family. KFDV is the cause of Kyasanur Forest Disease (KFD), a biphasic illness which is comprised of an acute and convalescent phases. The case fatality rate is reported to reach ~5%. The acute phase is characterized by frontal headache, fever, chills, body aches, hemorrhagic pneumonitis, parenchymatic degeneration, hepatomegaly, nephrosis, thrombocytopenia, leucopenia, anemia, elevated liver enzymes, and reticulo-endothelial cell findings in the liver and spleen. The convalescent phase symptoms may include hemorrhagic fever manifestations, bradycardia, conjunctival inflammation, meningoencephalitis, coma, stiff neck, abnormal reflexes, tremors, mental disturbance, light-headedness, and confusion. This Eyewiki article will focus solely on the ocular findings of KFDV.

Modes of Transmission

KFDV human transmission is caused by bites from infected Haemophysalis spinigera ticks or by contact with an infected animal, most commonly a sick or recently deceased monkey.

Epidemiology

KFDV is endemic to south India and was first identified in Karnataka, India in 1957. During the past five decades, an incidence of 400-500 KFDV cases are reported annually.

Pathophysiology

Although it is theorized that the ocular features of KFDV may result from the hemorrhagic nature of the virus or from an immune-mediated response, the ocular pathophysiology remains ill defined.

Primary Prevention

Currently there is no licensed human vaccine protective against KFDV despite it being listed by the National Institute of Allergy and Infectious Diseases (NIAID) as a risk group 4 (i.e., causes severe human disease and is a serious hazard to laboratory workers. Presents a high risk of spread to the community and there is usually no effective prophylaxis or treatment) and NIAID Category C priority pathogen (i.e. emerging pathogen that could be engineered for mass dissemination in the future because of availability; ease of production and dissemination; and potential for high morbidity and mortality rates and major health impact) . Therefore, preventive strategies focus on decreasing exposure by against tick vector exposure by using long-sleeved clothing as well as insect repellants, especially in endemic areas.

Ocular Manifestations

Ophthalmological features of KFDV may include keratitis, mild-moderate iritis, lenticular opacities, as well as conjunctival, vitreous and intraretinal hemorrhages. The most common ocular finding is conjunctival congestion in palpebral conjunctiva accompanied by serous discharge. Fundoscopic findings may include vitreous and retinal hemorrhages and less commonly, papilledema secondary to encephalitis. Due to the above mentioned clinical findings, the visual acuity may be reduced to 20/200 in some cases.

Diagnosis

Diagnostic testing for KFDV includes molecular tests (e.g., real time polymerase chain reaction (RT-PCR), IgG, and IgM antibody capture ELISA). Challenges with diagnosis of KFDV include the indistinguishable overlap of symptomology with other hemorrhagic fevers and the lack of a point-of-care diagnostic tool.

Ocular Signs

Conjunctival congestion, subconjunctival hemorrhage, superficial punctuate keratitis, mild-moderate iritis, retinal superficial and deep hemorrhage, retinal hard exudates, vitreous hemorrhage, as well as papilledema.

Ocular Symptoms

Conjunctivitis, diplopia, photophobia, vision loss

Differential Diagnoses

The following illnesses should be taken into consideration for the differential diagnoses of KFDV.

• Dengue virus/Dengue Hemorrhagic Fever
• Crimean-Congo hemorrhagic fever
• Rift Valley Fever
• Zika Virus
• Yellow Fever
• Japanese encephalitis Virus
• West Nile Virus
• Ebola Virus
• Marburg Virus
• Typhoid Fever
• Malaria
• Meningococcemia
• Leptospirosis
• Other Rickettsial infection
• Other Viral hemorrhagic fever

Management

General management includes early intervention and supportive therapy with fluid replacement.

Medical Therapy

Presently there is no FDA-approved treatment for KFDV infection. Iatrogenic use of aspirin, hepatotoxic analgesics, and non-steroid anti-inflammatory drugs need be avoided in order to reduce the risk of hemorrhagic complications.

Prognosis

The majority of patients with KFDV begin to recover after 14 days within a 7-14 period of remission. Although, in some cases decreased vision, photophobia, eye pain, may persist longer. Overall, long-term sequelae of infection are rare.

Summary

KFDV is associated with both anterior (acute hemorrhagic conjunctivitis) and/or posterior segment findings (retinal hemorrhages, papilledema). There is no proven effective treatment or vaccine for KFDV. Primary prevention focuses on reducing exposure to tick bite. Travel to or from south India is the main epidemiologic risk factor.

Additional Resources

https://www.cdc.gov/vhf/kyasanur/index.html