subepithelial infiltrates. The use of topical corticosteroids does not affect the natural course of the disease, and it may be difficult to wean patients from them. Nonsteroidal anti-inflammatory agents (NSAIDs) are ineffective therapy for adenoviral subepithelial infiltrates, but they may be helpful in preventing recurrence following tapering of the corticosteroids. Topical cyclosporine 1% or other immunomodulatory agents may be considered in patients failing other therapy.
Actively infected persons readily transmit adenoviruses. Viral shedding may persist for 10–14 days after the onset of clinical signs and symptoms. Transmission can be prevented by personal hygiene measures, including frequent hand washing; cleaning of towels, pillowcases, and handkerchiefs; and disposal of contaminated facial tissues. Individuals who work with the public, in schools, or in health care facilities in particular should consider a temporary leave of absence from work to prevent infecting others, especially those who are already ill. Patients should be considered infectious if they are still hyperemic and tearing. It is more difficult to assess transmissibility in patients treated with topical corticosteroids, as they may appear quiet but still shed the virus.
DNA Viruses: Poxviruses
The Poxviridae encompass a large family of enveloped, double-stranded DNA viruses, with a distinctive brick or ovoid shape and a complex capsid structure. The best-known poxviruses are molluscum contagiosum, vaccinia, and smallpox (variola) virus.
Molluscum Contagiosum
PATHOGENESIS Molluscum contagiosum virus is spread by direct contact with infected individuals. Infection produces 1 or more umbilicated nodules on the skin and eyelid margin and, less commonly, on the conjunctiva. Eyelid nodules release viral particles into the tear film.
CLINICAL PRESENTATION A molluscum nodule is smooth with an umbilicated central core. It is smaller and associated with less inflammation than a keratoacanthoma. Punctate epithelial erosions and, in rare cases, a corneal pannus may occur. Any chronic follicular conjunctivitis should instigate a careful search for eyelid margin molluscum lesions (Fig 4-20).
Figure 4-20 Multiple molluscum contagiosum nodules associated with a follicular conjunctivitis in an immunocompetent
child. (Reprinted with permission from Tu EY. Conjunctivitis. In: Schlossberg D, ed. Clinical Infectious Disease. 3rd ed. New York: Cambridge University Press; 2008.)
LABORATORY EVALUATION AND MANAGEMENT The molluscum contagiosum virus cannot be cultured using standard techniques. Histologic examination of an expressed or excised nodule shows eosinophilic, intracytoplasmic inclusions (Henderson-Patterson bodies) within epidermal cells. Diagnosis is based on detection of the characteristic eyelid lesions in the presence of a follicular conjunctivitis. Spontaneous resolution occurs but can take months to years. Treatment options include complete excision, cryotherapy, or incision of the central portion of the lesion. Extensive facial and eyelid molluscum lesions occur in association with AIDS (Fig 4-21).
Figure 4-21 Multiple molluscum contagiosum lesions on the eyelid of a patient with AIDS. (Courtesy of James Chodosh, MD.)
Vaccinia
Discussion of another poxvirus, vaccinia, was previously removed from the BCSC series because of the eradication of smallpox. More recently, however, concerns of bioterrorism have prompted the reinstitution of a vaccination program, especially for military personnel. Ocular complications from self-inoculation have resulted, including potentially severe periorbital pustules, conjunctivitis, and keratitis. Treatment includes topical trifluridine. Use of vaccinia-immune globulin (VIG) is controversial but is indicated for severe disease. Concern about the use of VIG stems from limited rabbit studies that demonstrated a possible increase in corneal scarring. Individuals who are immunosuppressed, atopic, pregnant, breast-feeding, allergic to the vaccine, or living with a highrisk household contact should not receive the vaccine because of the risk of the possibly fatal, progressive vaccinia.
Fillmore GL, Ward TP, Bower KS, et al. Ocular complications in the Department of Defense Smallpox Vaccination Program. Ophthalmology. 2004;111(11):2086–2093.
Neff JM, Lane JM, Fulginiti VA, Henderson DA. Contact vaccinia—transmission of vaccinia from smallpox vaccination. JAMA. 2002;288(15):1901–1905.