Bilateral herpes simplex epithelial keratitis in a patient with pemphigus foliaceus

Bilateral herpetic keratitis is a rare event and can occur in atopy, measles, and immunodeficiency. Long-term use of systemic steroids for any autoimmune condition also creates iatrogenic immunodeficiency. A 62-year-old female with Pemphigus Foliaceus who had been on long-term steroids presented with bilateral epithelial herpetic keratitis. She received topical ganciclovir 5 times daily for a total of 10 days and intravenous (iv) acyclovir 5–10 mg/kg for 2 weeks for diffuse periocular skin involvement. In 2 weeks, corneal lesions completely disappeared with intact epithelium and no stromal involvement. Treatment was discontinued as no further ocular signs were observed. Peroral antiviral prophylaxis was not initiated since systemic steroids were also discontinued. Three months after resolution, she underwent bilateral cataract surgeries with per-operative and post-operative systemic prophylaxis during topical steroid use. Long-term systemic steroid use seems to be a predisposing factor for bilateral herpetic ocular infections.