Keratoconjunctivitis could present as initial COVID-19 sympt
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A 29-year-old female 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 a history of traveling.

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.

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.