Supplementary Material for: Conjunctival phlyctenule and nodular scleritis in a patient with previous Herpes Simplex Virus-2 exposure —Causative Agent or Innocent Bystander?

Introduction: Phlyctenular keratoconjunctivitis is an inflammatory condition arising from a type IV hypersensitivity reaction, presenting with inflamed nodules on the conjunctiva and cornea. Scleritis is a severe ocular inflammation linked to systemic diseases, potentially vision-threatening, and involving immune responses similar to Phlyctenular keratoconjunctivitis. This case report discusses a patient with a history of HSV-2 infection who primarily developed phlyctenular conjunctivitis and later progressed to nodular scleritis.
Case Presentation: A 66-year-old female presented with pain, redness, and a foreign body sensation in her left eye for two days. Initial treatment for epidemic keratoconjunctivitis with tobramycin-dexamethasone improved her symptoms. However, three weeks later, she developed a conjunctival phlyctenule. Diagnostic tests, including blood work and conjunctival swabs, were conducted. While most tests were negative, HSV-2 IgG was positive. The patient failed topical corticosteroid monotherapy; however, she responded to oral valacyclovir. Follow-up examinations showed significant improvement, with resolution of the conjunctival phlyctenule and nodular scleritis, and her best-corrected visual acuity returned to 20/20.
Conclusion: This case highlights the importance of considering HSV-2 in atypical presentations of phlyctenular conjunctivitis and scleritis. The patient's response to antiviral therapy underscores the potential role of HSV-2 in such ocular inflammations. Thorough infectious workups and alternative treatment approaches are crucial in managing unconventional cases. Experimental treatments based on lab findings can be valuable for patients preferring conservative management, emphasizing the need for close follow-up and personalized care in ocular inflammatory diseases.