Possible viral agents to consider in the differential diagnosis of blepharoconjunctivitis

Table 1 Distinguishing features of blepharoconjunctivitis caused by different viruses, including herpes simplex virus, varicella-zoster virus, adenovirus, and enterovirus

Feature	Herpes simplex virus	Varicella-zoster virus	Adenovirus	Enterovirus
Common symptoms	Unilateral conjunctival redness, itching, vesicular lesions on eyelids, dendritic ulcers on cornea	Painful vesicular rash localized to a dermatome, conjunctivitis	Acute conjunctivitis with profuse, watery discharge, preauricular lymphadenopathy	Conjunctival hyperemia, lid swelling, profuse tearing, possible subconjunctival hemorrhage
Discharge type	Clear or watery; may have epithelial defects	Clear or serous; often accompanied by skin lesions	Watery; often profuse and accompanied by preauricular lymphadenopathy	Watery or serous; can be associated with hemorrhage
Onset	Sudden, often following reactivation of latent infection	Sudden, often follows a history of shingles or chickenpox	Acute onset, highly contagious	Acute onset, highly contagious
Preauricular lymphadenopathy	Rare	Rare	Common	Rare
Corneal involvement	Frequent; dendritic ulcers visible on fluorescein staining	Possible; less common but can have corneal involvement	Rare	Rare
Associated systemic symptoms	Fever, malaise, possibly cold sores	Painful rash in a dermatome, fever	Often accompanied by upper respiratory symptoms	May have systemic symptoms like fever, malaise, or rash
Diagnostic tests	PCR for HSV DNA, viral culture, direct fluorescent antibody	PCR for VZV DNA, viral culture	PCR for adenoviral DNA, viral culture	PCR for enteroviral RNA, viral culture
Immunoassays	Detect HSV-specific antigens or antibodies	Detect VZV-specific antigens or antibodies	Detect adenoviral antigens or antibodies	Detect enteroviral antigens or antibodies
Corneal examination	Dendritic ulcers, punctate epithelial keratopathy	Vesicular rash on eyelids and possible corneal involvement	Typically, no corneal involvement	Rarely involves the cornea
Epidemiology	Common, especially in individuals with a history of cold sores or HSV infections	Less common, typically in individuals with recent shingles or chickenpox	Highly contagious; common in children and adults	Less common, often associated with outbreaks
Management	Antiviral medications (e.g., acyclovir), topical or systemic steroids for inflammation	Antiviral medications, supportive care for rash and pain	Supportive care, antihistamines, sometimes antiviral treatment	Supportive care, analgesics for discomfort

PCR: Polymerase chain reaction; HSV: Herpes simplex virus; VZV: Varicella-zoster virus.