While conjunctival congestion is the most common ophthalmic manifestation of SARS-CoV-2 infection to date, clinicians report an orbital myositis found in a 10-year-old boy who tested positive for SARS-CoV-2 infection “in the absence of typical systemic COVID-19 manifestations,” according to a study published in the Journal of American Association for Pediatric Ophthalmology and Strabismus.

“Although it is uncertain whether SARS-CoV-2 infection triggered the inflammation or was coincidental, the possible association of the events is concerning,” researchers report.

The patient, healthy before the infection, came to Benha University in Banha, Egypt, with a 5-day history of left progressive periorbital dull-ache swelling. His upper eyelid was drooping and he had binocular horizontal diplopia on left gaze, painful eye movement, redness of the eye, low-grade fever, occasional nausea, and vomiting. He’d had contact 3 week prior to becoming sick with asymptomatic individuals who were seropositive for SARS-CoV-2, according to his mother. The child denied symptoms of cough, shortness of breath, or general malaise and was afebrile at presentation (37.5 ° C/99.5 ˚ F). 


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Best-corrected visual acuity was 20/20 in his right eye and 20/20 in the left eye, and intraocular pressures were 14 mm Hg in each eye. Orbital magnetic resonance imaging (MRI) showed significant enlargement of the left lateral rectus muscle, which included its belly and tendinous insertions, and the ipsilateral lacrimal gland, with “mild stranding of the surrounding intraorbital fat and consequent proptosis.” 

The patient had an elevated erythrocyte sedimentation rate (56 mm/h), positive C-reactive protein level, and positive nasopharyngeal swab reverse-transcriptase polymerase chain reaction (RT-PCR) tests for SARS-CoV-2. Home isolation for 2 weeks was advised because of the positive COVID test. A treatment regime of 5-day oral therapy with azithromycin (AZT) 200 mg/ 5 ml suspension (5 ml once daily) and oral prednisone (1 mg/kg/day) for 2 weeks were prescribed. 

Investigators found what they called “dramatic improvement” 2 days following the steroid regimen was started and at the 1-month follow-up examination, clinical features and proptosis had resolved completely. The oral prednisone therapy was tapered by 10 mg weekly, and on repeated orbital MRI 14 days after therapy was started, the swelling of the left lateral rectus muscle and lacrimal gland had resolved.

“In both reports and in our patient, systemic COVID-19 symptoms were either absent or mild,” the case study says. “In our patient, there was evidence of lateral rectus myositis, enlarged lacrimal gland, and signs of orbital inflammation. It is unclear whether SARS-CoV-2 infection triggered the orbital inflammation or was coincidental.”

Immunohistological research is needed to determine if the case was caused by direct viral infiltration or a sterile immunological process. “We speculate that viral particles may have entered…ocular tissues from respiratory droplets, blood spread of the virus via the lacrimal gland, or from the nasopharynx. It is also possible that SARS-CoV-2 infection induced an immunological process targeting orbital tissue. Autoimmune myositis has been reported as a manifestation of COVID-19 infection,” the investigators explain.

Reference

Eleiwa T, Abdelrahman SN, El Sheikh RH, Elhusseiny AM. Orbital inflammatory disease associated with COVID-19 infection. J AAPOS. Published online May 6, 2021. doi:10.1016/j.jaapos.2021.04.002