Keratoconjunctivitis could present as initial COVID-19 symptom

This is the first case report of COVID-19 with keratoconjunctivitis as the main presenting symptom.

Study design

The patient was a 29-year-old female with no significant medical history. She presented with the primary symptom of unilateral conjunctivitis, photophobia and clear watery discharge accompanied by rhinorrhea, cough and nasal congestion without fever. The patient took over-the-counter antipyretic medication, which may have masked a mild fever. She had recently returned from a 1-month vacation in the Philippines, with a stopover in San Francisco, before returning to Canada.

Outcomes

The patient was initially seen by her family doctor when symptoms started on March 1 and was referred to the ophthalmology service. Upon presentation on March 3, the patient complained of worsening symptoms of photophobia, a sore and swollen eyelid, and mucous discharge of the right eye. On examination, her vision was 20/20 OU and slit-lamp examination was remarkable for 1 to 2+ conjunctival injection, 3+ follicles, 1 small pseudodendrite and 8 small subepithelial infiltrates with overlying epithelial defects.

The patient was started on oral valacyclovir and topical moxifloxacin based on a presumed diagnosis of herpetic keratoconjunctivitis. Over the course the condition, the patient's vision declined to 20/40, she developed a right pre-auricular node and cervical lymphadenopathy. The patient was continued on oral valacyclovir and moxifloxacin drops, but a presumed diagnosis of EKC was given and contact precautions were suggested. A nasopharyngeal swab collected on March 8th was positive for detection of COVID-19 by a real-time reverse transcriptase PCR. Retrospective testing of an eye swab originally submitted for gonorrhea/chlamydia PCR on March 6th was found to be weakly positive for COVID-19.

Limitations

There was a delay in testing the patient for COVID-19 because the initial guidelines from the Government of Canada restricted testing based on country of travel and the Philippines was not initially included. The case report was limited to one patient in a single geographic location.

Clinical significance

This is the first documented case of COVID-19 presenting with keratoconjunctivitis. It is crucial for all front-line health care providers to be aware that COVID-19 patients can present with keratoconjunctivitis as the initial finding. Eye care professionals may be the first point of contact in the health care field for patients with possible COVID-19, before the onset of characteristic respiratory symptoms. The clinical presentation of COVID-19 in the eye can vary and fluctuate. Having a high index of suspicion would allow for close monitoring of potential COVID-19 patients and would lead to precautions taken to prevent further spread of COVID-19.