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Gandhi N, Das S, Mittal R, Barik MR. Microsporidial Endotheliitis Mimicking Graft Rejection After Deep Anterior Lamellar Keratoplasty. Cornea 2022; 41:782-784. [PMID: 34267060 DOI: 10.1097/ico.0000000000002813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/19/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to report a case of microsporidial endotheliitis masquerading as graft rejection after deep anterior lamellar keratoplasty (DALK). METHODS A 36-year-old man visited the clinic with complaints of blurred vision, redness, pain, watering, and whitish appearance of the black portion of his left eye. On evaluation, there was diffuse stromal edema with epithelial defect and hypopyon. Microbial keratitis resolved with macular grade scar. He underwent DALK. After 3 years, he presented with complaints of sudden diminution of vision in the same eye for 10 days. His unaided visual acuity was counting finger 1 meter. The clinical findings were circumcorneal congestion, diffuse graft edema, Descemet membrane folds, and diffuse keratic precipitates. A presumptive diagnosis of left eye graft rejection was made. Topical steroids were administered. There was significant improvement within a week. However, at 1 month, there was an increase in graft edema after the steroids were tapered. At this point, a diagnosis of endotheliitis of viral origin was made. He was then administered oral antivirals and steroids. There were 2 such waxing and waning episodes of graft edema before the graft failed. Patient underwent penetrating keratoplasty with cataract extraction with intraocular lens implantation. RESULTS The previous donor and host Descemet endothelium complex was sent for histopathology and polymerase chain reaction. Both histology and polymerase chain reaction were positive for microsporidia. CONCLUSIONS Microsporidial endotheliitis may present as graft rejection. There should be a suspicion of microsporidial infection in cases of features mimicking as endothelial rejection after DALK.
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Affiliation(s)
- Neha Gandhi
- Cornea & Anterior Segment Service, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | - Sujata Das
- Cornea & Anterior Segment Service, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | - Ruchi Mittal
- Kanupriya Dalmia Ophthalmic Pathology Laboratory, L V Prasad Eye Institute, Bhubaneswar, Odisha, India ; and
| | - Manas R Barik
- Ocular Microbiology Service, L V Prasad Eye Institute, MTC Campus, Bhubaneswar, Odisha, India
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2
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Yeh TC, Kuo YS, Wang LC, Tai TY, Lin PY. Chlorhexidine in the treatment of microsporidial stromal keratitis and the effect of host immunity: A case series and literature review. J Chin Med Assoc 2022; 85:532-536. [PMID: 35383705 DOI: 10.1097/jcma.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Microsporidial stromal keratitis is an increasingly well-known vision-threatening disease. A large proportion of cases are initially misdiagnosed as herpes simplex keratitis and treated with topical steroids. In most of such cases, medical treatment failed, and corneal transplantation was required. This study reported the results of 0.02% topical chlorhexidine used to treat three cases of microsporidial stromal keratitis and reviewed the literature on the outcomes of microsporidial stromal keratitis treatment. In the first case, histopathology of a specimen from penetrating keratoplasty (PK) revealed severe chronic inflammation involving the entire stromal layer but no microorganism activity after the application of topical chlorhexidine for 10 months. The second case exhibited complete resolution of keratitis after topical chlorhexidine. The patient in the third case did not respond to medical treatment, and therapeutic PK was performed. Histopathological examination revealed numerous microsporidial spores that had colonized in the mid and deep stroma, where few inflammatory cells were observed. These findings explain the variable microsporidial susceptibility to chlorhexidine, suggesting the crucial role of host immunity. In cases of host immunity, topical chlorhexidine may represent a promising option for the treatment of microsporidial stromal keratitis.
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Affiliation(s)
- Tsai-Chu Yeh
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yih-Shiuan Kuo
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Lei-Chi Wang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tzu-Yang Tai
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Pei-Yu Lin
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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3
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Raghavan A, Raja DR, Venkatapathy N, Rammohan R. A case of stromal microsporidiosis: medical strategies employed for successful resolution. BMJ Case Rep 2022; 15:e246233. [PMID: 35165126 PMCID: PMC8845186 DOI: 10.1136/bcr-2021-246233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 11/04/2022] Open
Abstract
We describe the diagnosis and successful management of a case of stromal microsporidiosis, an important emerging ocular disease. Stromal microsporidiosis is recalcitrant and very often requires therapeutic keratoplasty for effective eradication. We successfully managed a steroid-treated case diagnosed only after 9 months, with a combination of polyhexamethyl biguanide 0.04%, chlorhexidine 0.04% and fluconazole 0.3% eye drops supplemented with tablet albendazole. However, complete resolution was achieved only after epithelial debridement. Toxicity due to the drugs was not noted. Diagnostic delays, steroid use and inappropriate therapy are commonly observed in stromal microsporidiosis. In spite of these potential disadvantages, our case responded well with complete eradication of the infection. The disease being fairly indolent and slowly progressive, medical therapy should be continued, in the absence of progression or other complications. Epithelial debridement may facilitate healing.
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Affiliation(s)
- Anita Raghavan
- Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Coimbatore, Tamilnadu, India
| | - Devi Rosette Raja
- Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Coimbatore, Tamilnadu, India
| | - Narendran Venkatapathy
- Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Coimbatore, Tamilnadu, India
| | - Ram Rammohan
- Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Coimbatore, Tamilnadu, India
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4
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Huck A, Moore LE, Firestone BK, Siatkowski RL, Riaz KM. Diagnostic Utility of CDC DPDx for an Atypical Presentation of Infectious Crystalline Keratopathy-Like Infiltrate Secondary to Microsporidia. Cornea 2022; 41:109-112. [PMID: 34870625 DOI: 10.1097/ico.0000000000002715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/01/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To report a case of atypical infectious crystalline keratopathy-like stromal infection secondary to microsporidia wherein diagnosis of the causative organism was aided by use of the Center for Disease Control (CDC) DPDx program. METHODS We report the case of a 73-year-old woman who presented with atypical infectious crystalline keratopathy-like corneal infection without previous surgical history. RESULTS The patient had previously been treated for recalcitrant corneal infection with topical antibiotics and steroids at an outside provider before referral. Further treatment with topical fortified antibiotics failed to improve the infection. Corneal biopsy was performed and sent to the CDC DPDx for diagnostic confirmation for presumptive microsporidia. The patient underwent therapeutic penetrating keratoplasty without recurrence of ocular infection. CONCLUSIONS Utilization of the DPDx resource may help guide appropriate and timely diagnosis and management strategies in atypical presentations of infectious keratitis.
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Affiliation(s)
- Andrew Huck
- Dean McGee Eye Institute/University of Oklahoma, Oklahoma City, OK
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5
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Matoba A, Goosey J, Chévez-Barrios P. Microsporidial Stromal Keratitis: Epidemiological Features, Slit-Lamp Biomicroscopic Characteristics, and Therapy. Cornea 2021; 40:1532-1540. [PMID: 33782266 DOI: 10.1097/ico.0000000000002704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/18/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Microsporidial stromal keratitis is a rare form of infectious keratitis, with only 7 cases reported in the United States to date. This study was performed to evaluate risk factors, clinical features, and response to therapy. METHODS A retrospective review of the medical records of all patients diagnosed with microsporidial stromal keratitis seen in the practices of the authors between 1999 and 2020 was performed. Diagnosis was determined by cytology or histopathology in corneal specimens. Risk factors, presence or absence of distinctive clinical features, and response to medical and surgical therapies were recorded. RESULTS Nine patients-7M:2F, aged 7 to 99 years-with microsporidial stromal keratitis were identified. Exposures to recreational water and hymenopteran insect bites, both epidemiologically linked risk factors for systemic microsporidial infection, were identified in our patients. Presence of stromal edema with features of disciform keratitis and a distinctive granular keratitis were observed in 6 of 9 and 5 of 9 patients, respectively. Poor response to medical therapy was noted. Penetrating keratoplasty was effective in curing the infection. Final visual acuity was 20/40 or better in 6 of 9 patients. CONCLUSIONS In patients with slowly progressive keratitis, history of exposure to recreational water or hymenopteran insects should be sought. In patients with corneal edema consistent with disciform keratitis, with evolution to a granular keratitis, microsporidia should be considered in the differential diagnosis. In cases of established microsporidial stromal keratitis, penetrating keratoplasty should be considered if prompt response to medical therapy is not noted.
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Affiliation(s)
- Alice Matoba
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX
| | | | - Patricia Chévez-Barrios
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX; and
- Departments of Pathology and Laboratory Medicine, and Ophthalmology, Weill Medical College of Cornell University, New York City, NY
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6
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Nguyen HT, Pham ND, Mai TQ, Do HTT, Nguyen DTN, McCluskey P, Pham TV. Tectonic Deep Anterior Lamellar Keratoplasty to Treat Corneal Perforation and Descemetocele from Microbial Keratitis. Clin Ophthalmol 2021; 15:3549-3555. [PMID: 34465975 PMCID: PMC8403223 DOI: 10.2147/opth.s324390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/11/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the result of tectonic deep anterior lamellar keratoplasty (DALK) for keratitis with perforation and descemetocele. Patients and Methods A prospective clinical study of 36 patients (36 eyes) treated with tectonic DALK for corneal perforation or descemetocele from microbial keratitis managed at the Vietnam National Eye Hospital over a two-year period. The surgical technique was manual lamellar dissection. The grafts were harvested from the anterior corneal cap of pre-cut donor tissues used for DSAEK or donor corneas with a low endothelial cell count. Results A mean age was 55.36 ± 13.98 years (ranged from 25 to 75 years). Female gender represented 52%. causative agents were herpes simplex virus (58.3%), bacteria (22.2%), fungi (13.9%) and microsporidia (5.6%). There were 24 eyes with descemetocele (66.7%) and 12 with perforation (33.3%). There were 33 successful cases (91.7%) and 3 failed cases (8.3%). Best corrected visual acuity (BCVA) improved in 28 eyes (84.8%). The range of post-operative BCVA was from hand motions to 20/70. Eleven eyes (33.3%) attained vision 20/200 and higher. Clear graft was obtained in 15 eyes (45.5%), while mild or severe graft opacity was observed in 14 eyes (42.4%), and 4 eyes (12.1%), respectively. Surgical complications included descemet rupture (20.8%), pseudo anterior chamber (41.6%), persistent corneal epithelial defects (8.3%), reinfection (11.1%), glaucoma or ocular hypertension (5.6%) and cataract (8.3%). Conclusion The study demonstrates that DALK is an effective procedure to treat corneal descemetocele, especially when an urgent penetrating keratoplasty (PKP) cannot be performed.
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Affiliation(s)
- Hong The Nguyen
- Department of Ophthalmology, 108 Military Central Hospital, Hanoi, Vietnam.,Department of Ophthalmology, Hanoi Medical University, Hanoi, Vietnam
| | - Ngoc Dong Pham
- Department of Cornea, Vietnam National Eye Hospital, Hanoi, Vietnam
| | - Tung Quoc Mai
- Department of Ophthalmology, Hanoi Medical University, Hanoi, Vietnam
| | - Hang Thi Thuy Do
- Department of Cornea, Vietnam National Eye Hospital, Hanoi, Vietnam
| | | | - Peter McCluskey
- Department of Ophthalmology, University of Sydney, Sydney, NSW, Australia
| | - Trong Van Pham
- Department of Ophthalmology, Hanoi Medical University, Hanoi, Vietnam
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7
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Donovan CP, Margo CE, Espana EM. Stromal microsporidial keratitis successfully treated with medical therapy. Am J Ophthalmol Case Rep 2021; 23:101178. [PMID: 34368500 PMCID: PMC8326187 DOI: 10.1016/j.ajoc.2021.101178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/27/2021] [Accepted: 07/19/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose To report a case of severe stromal microsporidal keratitis successfully treated with oral albendazole and topical voriconazole. Observations A 71-year-old man presented with progressive vision loss and corneal opacification for one year. Initial visual acuity was counting fingers attributed to a dense subepithelial opacification. Confocal microscopy and subsequent corneal biopsy lead to the diagnosis of microsporidial keratitis. The patient completed a four-week course of oral albendazole and topical voriconazole which resulted in resolution of the corneal opacification and improvement in visual acuity to 20/250. Conclusions and Importance A four-week course of oral albendazole and topical voriconazole was an effective treatment for severe stromal microsporidial keratitis.
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Affiliation(s)
- Christopher P. Donovan
- Department of Ophthalmology, University of South Florida, Morsani College of Medicine, 13330 USF Laurel Drive, 4th Floor, Tampa, FL, 33612, USA
| | - Curtis E. Margo
- Department of Ophthalmology, University of South Florida, Morsani College of Medicine, 13330 USF Laurel Drive, 4th Floor, Tampa, FL, 33612, USA
- Department of Pathology and Cell Biology, University of South Florida, Morsani College of Medicine, 12901 Bruce B. Downs Blvd., MDC 11, Tampa, FL, 33612, USA
| | - Edgar M. Espana
- Department of Ophthalmology, University of South Florida, Morsani College of Medicine, 13330 USF Laurel Drive, 4th Floor, Tampa, FL, 33612, USA
- Department of Molecular Pharmacology and Physiology, University of South Florida, Morsani College of Medicine, 12901 Bruce B. Downs Blvd, MDC 8, Tampa, FL, 33612, USA
- Corresponding author. University of South Florida Eye Institute, Morsani College of Medicine, 13330 USF Laurel Dr, Tampa, FL, 33612.
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Abstract
Microsporidia are obligate intracellular pathogens identified ∼150 years ago as the cause of pébrine, an economically important infection in silkworms. There are about 220 genera and 1,700 species of microsporidia, which are classified based on their ultrastructural features, developmental cycle, host-parasite relationship, and molecular analysis. Phylogenetic analysis suggests that microsporidia are related to the fungi, being grouped with the Cryptomycota as a basal branch or sister group to the fungi. Microsporidia can be transmitted by food and water and are likely zoonotic, as they parasitize a wide range of invertebrate and vertebrate hosts. Infection in humans occurs in both immunocompetent and immunodeficient hosts, e.g., in patients with organ transplantation, patients with advanced human immunodeficiency virus (HIV) infection, and patients receiving immune modulatory therapy such as anti-tumor necrosis factor alpha antibody. Clusters of infections due to latent infection in transplanted organs have also been demonstrated. Gastrointestinal infection is the most common manifestation; however, microsporidia can infect virtually any organ system, and infection has resulted in keratitis, myositis, cholecystitis, sinusitis, and encephalitis. Both albendazole and fumagillin have efficacy for the treatment of various species of microsporidia; however, albendazole has limited efficacy for the treatment of Enterocytozoon bieneusi. In addition, immune restoration can lead to resolution of infection. While the prevalence rate of microsporidiosis in patients with AIDS has fallen in the United States, due to the widespread use of combination antiretroviral therapy (cART), infection continues to occur throughout the world and is still seen in the United States in the setting of cART if a low CD4 count persists.
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Scurrell E, Manning S, Malho P, Civello A, Mould J, Carrozza R, Wagner BE. Microsporidial keratopathy in two dogs. Vet Ophthalmol 2019; 23:402-408. [PMID: 31758652 DOI: 10.1111/vop.12726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/07/2019] [Accepted: 10/28/2019] [Indexed: 11/29/2022]
Abstract
A microsporidial keratopathy is described in two dogs. Both dogs presented with a unilateral stromal keratopathy characterized by multifocal coalescing opacities, and the diagnosis was made on histopathologic examination of keratectomy specimens. Transmission electron microscopy (TEM) on formalin-fixed, paraffin-embedded corneal tissue was performed in one dog, and the morphologic features were consistent with Nosema species infection. Both dogs were initially diagnosed and treated by superficial keratectomy. One dog received additional antifungal medication and underwent a penetrating keratoplasty following local recurrence two years later. No other systemic lesions attributable to the microsporidial infection were identified clinically. The clinical and diagnostic pathology findings, treatment, and follow-up are discussed.
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Affiliation(s)
| | | | | | | | - John Mould
- Eye Veterinary Clinic, Leominster, Herefordshire, UK
| | | | - Bart E Wagner
- Electron Microscopy Suite, Department of Histopathology, Royal Hallamshire Hospital, Sheffield, UK
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Jeklová E, Levá L, Kummer V, Jekl V, Faldyna M. Immunohistochemical Detection of Encephalitozoon cuniculi in Ocular Structures of Immunocompetent Rabbits. Animals (Basel) 2019; 9:ani9110988. [PMID: 31752146 PMCID: PMC6912405 DOI: 10.3390/ani9110988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/14/2019] [Accepted: 11/14/2019] [Indexed: 11/16/2022] Open
Abstract
Encephalitozoonosis is a common infectious disease widely spread among rabbits. Its causative agent, Encephalitozoon cuniculi, is considered as a zoonotic and emerging pathogen capable of infecting both immunocompetent and immunocompromised hosts, including humans. In rabbits, clinical signs include neurological, kidney and ocular disease. The aim of this study was to detect E. cuniculi in ocular structures in immunocompetent rabbits after experimental oral infection using immunohistochemistry. In infected animals, E. cuniculi spores were present in periocular connective tissue, sclera, cornea, choroidea, iris, retina and lens, as a round to ovoid organism reacting with a specific anti-E. cuniculi monoclonal antibody as early as 2 weeks after infection. There were no signs of inflammatory lesions in any of the ocular tissues examined at 2, 4, 6 and 8 weeks after infection. In the present study, E. cuniculi was also detected in the lenses of adult rabbits, which indicates that ways of lens infection other than intrauterine and haematogenic are possible.
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Affiliation(s)
- Edita Jeklová
- Veterinary Research Institute, Hudcova 296/70, 621 00 Brno, Czech Republic; (E.J.); (L.L.); (V.K.)
| | - Lenka Levá
- Veterinary Research Institute, Hudcova 296/70, 621 00 Brno, Czech Republic; (E.J.); (L.L.); (V.K.)
| | - Vladimír Kummer
- Veterinary Research Institute, Hudcova 296/70, 621 00 Brno, Czech Republic; (E.J.); (L.L.); (V.K.)
| | - Vladimír Jekl
- Jekl & Hauptman Veterinary Clinic, Mojmírovo nám. 3105/6a, 612 00 Brno, Czech Republic;
| | - Martin Faldyna
- Veterinary Research Institute, Hudcova 296/70, 621 00 Brno, Czech Republic; (E.J.); (L.L.); (V.K.)
- Correspondence:
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Liu HY, Chu HS, Wang IJ, Chen WL, Hu FR. Microbial Keratitis in Taiwan: A 20-Year Update. Am J Ophthalmol 2019; 205:74-81. [PMID: 30951687 DOI: 10.1016/j.ajo.2019.03.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/17/2019] [Accepted: 03/23/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE To investigate the demographics, risk factors, microbiology, and resistance pattern at a tertiary hospital and to detect the shifting trend over 2 decades. DESIGN A retrospective observational case series. METHODS We reviewed all records of patients with microbial keratitis (MK) that were hospitalized in National Taiwan University Hospital between 2007 and 2016. Demographics, predisposing factors, pathogens, and clinical courses were compared to our previous study conducted from 1992 to 2001. Antibiotic susceptibility was compared with those conducted from 1994 to 2005. RESULTS The percentage of patients 60 years and older in the MK population was increasing (P = 2.1E-21). The proportion of trauma-related MK declined while MK related to chronic ocular or systemic disorders rose. The prevalence of nontuberculous mycobacteria (NTM) showed a decreasing trend (P = .0032), whereas Microsporidia has been increasingly detected. The 2 most common bacterial isolates were Pseudomonas aeruginosa (35.2%) and Staphylococcus species (13.2%). Management of these infection did not differ in common pathogens between the 2 decades. The susceptibility of Staphylococcus species to oxacillin reduced significantly (P = .002) and there was an increase in methicillin-resistant Staphylococcus aureus keratitis. CONCLUSIONS Contact lens wear remained the most common predisposing factor, with Pseudomonas species as the major pathogen. However, chronic disorder-related MK was on the rise along with an increasing trend of oxacillin resistance in Staphylococcus species. We found a decreasing trend in NTM keratitis while Microsporidia keratitis was considered as an emerging ocular disease. Though gram-negative isolates remained susceptible to all antibiotics tested, antibiotic resistance was more common in gram-positive isolates.
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Affiliation(s)
- Hsin-Yu Liu
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiao-Sang Chu
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Jong Wang
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Li Chen
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Fung-Rong Hu
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan.
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Ueno S, Eguchi H, Hotta F, Fukuda M, Kimura M, Yagita K, Suzuki T, Kusaka S. Microsporidial keratitis retrospectively diagnosed by ultrastructural study of formalin-fixed paraffin-embedded corneal tissue: a case report. Ann Clin Microbiol Antimicrob 2019; 18:17. [PMID: 31182106 PMCID: PMC6558824 DOI: 10.1186/s12941-019-0316-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 06/06/2019] [Indexed: 01/07/2023] Open
Abstract
Background The utility of formalin-fixed paraffin-embedded (FFPE) corneal tissue specimens for retrospective diagnosis of microsporidial keratitis was evaluated by transmission electron microscopy (TEM) analysis and the possible second case of microsporidial keratitis after Descemet stripping automated endothelial keratoplasty (DSAEK) was described. Case presentation A 68-year-old man presented with multiple crystalline opacities in the corneal stroma that progressed extremely slowly after DSAEK. Fungiflora Y staining of corneal scrapings from the affected regions revealed an oval microorganism. Topical voriconazole administration was ineffective and penetrating keratoplasty was performed. Histological and molecular analyses were carried out on the excised cornea. Ziehl–Neelsen staining revealed an acid-fast, oval organism that was visible by ultraviolet illumination after Fungiflora Y and Uvitex 2B staining, whereas periodic acid-Schiff and Grocott’s staining did not yield any significant findings. Microsporidium was detected by TEM of FFPE tissue. Nosema or Vittaforma sp. was suspected as the causative microorganism by PCR of FFPE tissue and by the fact that those species are known to cause eye infection. The corneal graft has maintained transparency at 1 year and half postoperatively. Conclusions This is the first known case of microsporidial keratitis diagnosed retrospectively by molecular and ultrastructural study of FFPE tissue, and the possible second case of microsporidial keratitis after DSAEK. Microsporidial keratitis should be considered when corneal opacity refractory to conventionally known therapy would occur after DSAEK. Our findings suggest that more microsporidial keratitis cases than have been reported to date can be identified by TEM or PCR examination of FFPE corneal specimens.
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Affiliation(s)
- Satoru Ueno
- Department of Ophthalmology, Kindai University Faculty of Medicine, 377-2, Ohnohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Hiroshi Eguchi
- Department of Ophthalmology, Kindai University Faculty of Medicine, 377-2, Ohnohigashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Fumika Hotta
- Department of Ophthalmology, Kindai University Faculty of Medicine, 377-2, Ohnohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Masahiko Fukuda
- Department of Ophthalmology, Kindai University Faculty of Medicine, 377-2, Ohnohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Masatomo Kimura
- Department of Pathology, Kindai University Faculty of Medicine, 377-2, Ohnohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Kenji Yagita
- Department of Parasitology, National Institute of Infectious Diseases, 1-23-1, Toyama, Shinjuku, Tokyo, 162-8640, Japan
| | - Takashi Suzuki
- Department of Ophthalmology, Toho University Medical Center, 6-11-1, Ohmorinishi, Ota, Tokyo, 143-8541, Japan
| | - Shunji Kusaka
- Department of Ophthalmology, Kindai University Faculty of Medicine, 377-2, Ohnohigashi, Osakasayama, Osaka, 589-8511, Japan
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Leroy J, Cornu M, Deleplancque AS, Bart A, Loridant S, Fréalle E, Dutoit E, Gaillot O, van Gool T, Puisieux F, Labalette P, Sendid B. Case Report: Ocular Microsporidiosis: Case in a Patient Returning from India and Review of the Literature. Am J Trop Med Hyg 2018; 99:90-93. [PMID: 29692301 DOI: 10.4269/ajtmh.18-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Microsporidia are protists close to the kingdom of fungi that may cause eye infections. Most cases are reported in Asia and affect both immunocompromised and immunocompetent patients. Here, we report a rare case of microsporidial keratoconjunctivitis in an immunocompetent French patient 3 weeks after returning from India. In our patient, Weber trichrome staining of conjunctival scrapings revealed rounded elements approximately 1-3 μm in size. Conventional polymerase chain reaction analysis by ribosomal RNA subunit sequencing showed 100% identity with Vittaforma corneae. Treatment by corneal debridement combined with fluoroquinolone eye drops allowed complete resolution of the lesions. Although rare, ocular microsporidiosis should be investigated in a patient who is native to Asia or has returned from an endemic area and presents with keratoconjunctivitis of undetermined etiology.
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Affiliation(s)
- Jordan Leroy
- Institut National de la Santé et de la Recherche Médicale, Unité 995-Lille Inflammation Research International Center, Fungal Associated Invasive & Inflammatory Diseases, Lille, France.,Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | - Marjorie Cornu
- Institut National de la Santé et de la Recherche Médicale, Unité 995-Lille Inflammation Research International Center, Fungal Associated Invasive & Inflammatory Diseases, Lille, France.,Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | | | - Aldert Bart
- Department of Medical Microbiology, Section Parasitology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Séverine Loridant
- Institut National de la Santé et de la Recherche Médicale, Unité 995-Lille Inflammation Research International Center, Fungal Associated Invasive & Inflammatory Diseases, Lille, France.,Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | - Emilie Fréalle
- Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | - Emmanuel Dutoit
- Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | - Olivier Gaillot
- Service de Bactériologie, Lille University Hospital, Lille, France
| | - Tom van Gool
- Department of Medical Microbiology, Section Parasitology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Pierre Labalette
- Service d'Ophtalmologie, Lille University Hospital, Lille, France
| | - Boualem Sendid
- Institut National de la Santé et de la Recherche Médicale, Unité 995-Lille Inflammation Research International Center, Fungal Associated Invasive & Inflammatory Diseases, Lille, France.,Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
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Microsporidial Stromal Keratitis: Clinical Features, Unique Diagnostic Criteria, and Treatment Outcomes in a Large Case Series. Cornea 2017; 35:1569-1574. [PMID: 27467044 DOI: 10.1097/ico.0000000000000939] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe the history, clinical features, and outcomes of a large case series of microsporidial stromal keratitis with emphasis on probable predictors of the etiology in this rare and unspecified form of keratitis. METHODS Retrospective analysis of cases seen between January, 2002, and December, 2013, diagnosed at LV Prasad Eye Institute as having microsporidial stromal keratitis based on clinical, microbiology, and histopathology examination. Outcomes of medical and surgical management with visual recovery were documented. RESULTS There were 34 cases of microsporidial stromal keratitis with a mean age of 43.3 years (range 2-77 years) and male preponderance. The duration of symptoms was chronic in most cases (mean duration of 288 days). Nearly half of the cases had a history of trauma, in the age group of 20 to 50 years. The most common clinical misdiagnosis was herpes simplex virus keratitis (26.5%) followed by fungal keratitis (17.6%). This could be attributed to the nonspecific clinical picture of diffuse multifocal stromal lesions in 82.4% of cases. The organisms were detected in microbiological evaluation of corneal scrapings in 47% cases, and histopathological detection of the organisms showed a positivity rate of 92.3%. Surgical management was necessary in the majority of the cases (73.5% of patients). CONCLUSIONS The typical history of trauma with a smoldering, diffuse form of keratitis refractory to conventional medical therapy, responding to surgical removal for recovery is clearly demonstrated as a recurring feature in the majority of the cases. Patients presenting with this characteristic clinical picture should be suspected to harbor this rare pathogen, and early surgical interventions should be considered.
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Martel-Arquette A, Chen S, Hempstead J, Pacheco R, Antinoff N, Teixeira L. Microsporidial Keratoconjunctivitis in a Pet Bearded Dragon ( Pogona vitticeps ). J Exot Pet Med 2017. [DOI: 10.1053/j.jepm.2017.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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16
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Mittal R, Balne PK, Sahu S, Das S, Sharma S. Coexistence of herpes simplex virus infection in microsporidial stromal keratitis associated with granulomatous inflammation. Indian J Ophthalmol 2017; 65:276-281. [PMID: 28513490 PMCID: PMC5452578 DOI: 10.4103/ijo.ijo_761_15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Microsporidial stromal keratitis poses several diagnostic challenges. Patients may present with corneal ulceration, marked stromal thinning, or even as a quite corneal scar. The presentation of microsporidial stromal keratitis commonly mimics viral keratitis. Microbiology scrapings are usually helpful; however, scraping and culture-negative cases pose a significant diagnostic dilemma. Histopathological examination is diagnostic but shows varying degree of inflammation, predominantly composed of polymorphonuclear leukocytes. Granulomatous inflammation, in microsporidial stromal keratitis, is never well described, and the authors in this article aim to describe the presence of granulomatous inflammation in microsporidial stromal keratitis, in patients with associated herpes simplex virus (HSV) keratitis. Methods: This was a retrospective and observational study conducted at a tertiary eye care center. Results: Of 263 patients who underwent therapeutic penetrating keratoplasty for infectious keratitis, during 2011–2013, seven patients were diagnosed as microsporidial stromal keratitis. Microsporidial spores could be demonstrated on microbiological scrapings in 5/7 (71%) of cases, but identified on histopathological examination and also confirmed on polymerase chain reaction (PCR) for microsporidium in 100% of cases. There was evidence of diffuse stromal necrosis with markedly severe degree of polymorphonuclear leukocytic infiltrates, with granulomatous inflammation in 42% of cases. Interestingly, these were positive for HSV-1 DNA on PCR. Review of medical records revealed much severe clinical presentations in patients with granulomatous inflammation, in comparison to cases without granulomatous inflammation. Conclusions: The authors hereby recommend that severe clinical presentation in patients with microsporidial stromal keratitis, markedly dense polymorphonuclear leukocytic infiltrates or the presence of granulomatous inflammation on the histopathological examination, should be investigated further for the presence of HSV-1 DNA for better patient management and good visual outcome.
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Affiliation(s)
- Ruchi Mittal
- Dalmia Ophthalmic Pathology Services, L. V. Prasad Eye Institute, Bhubaneswar, Orissa, India
| | - Praveen K Balne
- Ocular Microbiology Services, L. V. Prasad Eye Institute, Bhubaneswar, Orissa; Jhaveri Microbiology Centre, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
| | - Srikant Sahu
- Department of Cornea and Anterior Segment Services, Tej Kohli Cornea Institute, L. V. Prasad Eye Institute, Bhubaneswar, Orissa, India
| | - Sujata Das
- Department of Cornea and Anterior Segment Services, Tej Kohli Cornea Institute, L. V. Prasad Eye Institute, Bhubaneswar, Orissa, India
| | - Savitri Sharma
- Ocular Microbiology Services, L. V. Prasad Eye Institute, Bhubaneswar, Orissa; Jhaveri Microbiology Centre, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
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Gulias Cañizo R, Hernandez Ayuso Y, Rios y Valles D, Sanchez Huerta V, Rodríguez Reyes AA. Microsporidiosis corneal. Reporte de casos y revisión de la literatura. REVISTA MEXICANA DE OFTALMOLOGÍA 2017. [DOI: 10.1016/j.mexoft.2015.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Coca M, Kim J, Shenoy S, Chévez-Barrios P, Kapur M. Microsporidial Stromal Keratitis: Successful Treatment with Topical Voriconazole and Oral Itraconazole. Cureus 2016; 8:e934. [PMID: 28123915 PMCID: PMC5258192 DOI: 10.7759/cureus.934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
We report a case of microsporidial stromal keratitis successfully treated with topical voriconazole and oral itraconazole. A 30-year-old Hispanic male construction worker who wears contacts lenses presented with left eye erythematous, epiphora, and mild pain increasing over few days after failing previous antibiotics treatment. His best corrected visual acuity in the left eye was count fingers at three feet, and the slit lamp examination showed 3+ conjunctival injection, a circular central corneal ulcer 3.2 mm in diameter, stromal thinning, and an anterior chamber with white cells, flair, and 0.1 mm hypopyon. A cornea punch biopsy identified microsporidial organisms with some features suggestive of Vittaforma corneae. After treatment with topical voriconazole and oral itraconazole for eight weeks, the patient had complete resolution with no recurrence for over 12 months of follow-up. To our knowledge, this is the first reported case of successful treatment of microsporidial stromal keratitis with antifungals.
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Affiliation(s)
- Mircea Coca
- Chicagoland Retinal Consultants ; Ophthalmology, UTMB
| | - James Kim
- Ophthalmology, Froedtert Eye Institute, Medical College of Wisconsin, Milwaukee, WI
| | | | - Patricia Chévez-Barrios
- Department of Pathology and Genomic Medicine, Department of Ophthalmology, Houston Methodist Hospital, Houston, TX
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19
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Ocular parasitoses: A comprehensive review. Surv Ophthalmol 2016; 62:161-189. [PMID: 27720858 DOI: 10.1016/j.survophthal.2016.09.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 09/27/2016] [Accepted: 09/29/2016] [Indexed: 12/14/2022]
Abstract
Parasitic infections of the eyes are a major cause of ocular diseases across the globe. The causative agents range from simple organisms such as unicellular protozoans to complex metazoan helminths. The disease spectrum varies depending on the geographic location, prevailing hygiene, living and eating habits of the inhabitants, and the type of animals that surround them. They cause enormous ocular morbidity and mortality not because they are untreatable, but largely due to late or misdiagnosis, often from unfamiliarity with the diseases produced. We provide an up-to-date comprehensive overview of the ophthalmic parasitoses. Each section describes the causative agent, mode of transmission, geographic distribution, ocular pathologies, and their management for common parasites with brief mention of the ones that are rare.
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20
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Sood AB, Debiec MR, Yeh S, Grossniklaus HE, Randleman JB. Microsporidial stromal keratitis and endophthalmitis in an immunocompetent patient. J Ophthalmic Inflamm Infect 2016; 6:30. [PMID: 27528053 PMCID: PMC5007235 DOI: 10.1186/s12348-016-0099-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 08/02/2016] [Indexed: 11/22/2022] Open
Abstract
Purpose The purpose of this study is to report a case of microsporidial endophthalmitis after penetrating keratoplasty in a healthy patient and discuss the management. Methods This is a case report. Results A 69-year-old healthy male underwent penetrating keratoplasty for corneal scar secondary to herpes stromal keratitis. He presented with features of acute graft rejection 3 years later. After failure of medical management, a repeat full thickness keratoplasty was performed. Pathologic examination of the corneal specimen showed microsporidia. The patient then developed a chronic endophthalmitis, and a vitreous tap and injection followed by pars plana vitrectomy were performed. Pathologic examination of tissue showed microsporidia. Conclusions Microsporidia are being increasingly identified as the cause of stromal keratitis. This is the first report of microsporidial endophthalmitis in a patient without underlying systemic illness.
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Affiliation(s)
- Arjun B Sood
- Department of Ophthalmology, Emory University, Atlanta, GA, USA. .,Emory Eye Center, Atlanta, GA, USA.
| | | | - Steven Yeh
- Department of Ophthalmology, Emory University, Atlanta, GA, USA.,Emory Eye Center, Atlanta, GA, USA
| | - Hans E Grossniklaus
- Department of Ophthalmology, Emory University, Atlanta, GA, USA.,Emory Eye Center, Atlanta, GA, USA
| | - J Bradley Randleman
- Department of Ophthalmology, Keck School of Medicine of USC, Los Angeles, CA, USA.,USC Roski Eye Institute, Los Angeles, CA, USA
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Sridhar U, Ur Rahman AA, Batra J, Sapra N. Ocular Microsporidiosis—Our Experience in a Tertiary Care Centre in North India. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/ojoph.2015.53020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Microsporidia are a diverse group of obligate, intracellular, eukaryotic, spore-forming parasites. Traditionally, these were considered as protozoans but recently have been reclassified as fungi. Microsporidia behave as opportunistic pathogens causing systemic infections. In the eye, Microsporidia cause keratoconjunctivitis, corneal stromal keratitis, scleritis, and endophthalmitis. This review shares our experiences with anterior segment infections caused by this pathogen. Keratoconjunctivitis is a common form of ocular infection caused by the parasite. Although early reports described it as occurring only in immunosuppressed individuals, it can also occur in immunocompetent individuals. The disease shows a seasonal pattern with a peak incidence during the rainy season. Although several drugs have been considered, our experience suggests that keratoconjunctivitis is a self-limiting disease. In contrast to keratoconjunctivitis, stromal keratitis is an ill-defined disease. We collected 30 cases and analyzed the various aspects of this disease. Stromal keratitis is characterized by a slowly progressive course. The corneal picture resembles herpes simplex virus stromal keratitis or fungal keratitis cases, and is characterized by deep stromal infiltrates with overlying and surrounding stromal edema and keratic precipitates. The diagnosis of Microsporidia infection is confirmed by a microscopic examination of smears from patients with ulcerative keratitis or by a histopathological examination of corneal tissues. Definitive genus identification requires the examination of specimens by electron microscopy or by molecular methods. In the absence of a definitive medical treatment, nearly all patients require surgical treatment. The confusion regarding Microsporidia is not only limited to their classification but also extends to various aspects of the corneal disease caused by them.
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Murthy SI, Sangit VA, Rathi VM, Vemuganti GK. Microsporidial spores can cross the intact Descemet membrane in deep stromal infection. Middle East Afr J Ophthalmol 2013; 20:80-2. [PMID: 23580858 PMCID: PMC3617535 DOI: 10.4103/0974-9233.106399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a rare case of a deep stromal keratitis with a chronic indolent course, diagnosed as microsporidial keratitis from corneal scrapings. The patient's condition worsened despite medical therapy and penetrating keratoplasty was performed. The histopathology of the corneal tissue revealed multiple microsporidial spores in the posterior stroma and the endothelial exudates, whereas there was no clinical or histopathological breach in Descemet's membrane. This is the second report in the literature to report that micropsoridial spores can cross the intact Descemet's membrane.
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Affiliation(s)
- Somasheila I Murthy
- Department of Cornea and Anterior Segment Service, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Andhra Pradesh, India
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Fan NW, Lin PY, Chen TL, Chen CP, Lee SM. Treatment of microsporidial keratoconjunctivitis with repeated corneal swabbing. Am J Ophthalmol 2012; 154:927-933.e1. [PMID: 22959880 DOI: 10.1016/j.ajo.2012.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 06/10/2012] [Accepted: 06/13/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the effect of repeated corneal swabbing in patients with microsporidial keratoconjunctivitis. DESIGN Retrospective noncomparative case series. METHODS Sixteen eyes of 14 healthy patients with microsporidial keratoconjunctivitis were diagnosed based on the detection of microsporidia in corneal scrapings using Gram stain, the modified Kinyoun acid-fast stain, or both. Polymerase chain reaction plus gene analysis of the microsporidian 16S ribosomal RNA had been performed in 10 patients who sought treatment between 2010 and 2011. Some of the lesions were scraped for procurement of specimens. The remaining lesions were wiped off gently by cotton swabs. Repeated swabbing was performed if infection persisted or new lesions were observed at follow-up. To prevent secondary bacterial infection, 0.3% norfloxacin or 0.25 % chloramphenicol were prescribed. RESULTS The mean age was 52.2 years. All patients had the characteristic disseminated, punctate, slightly elevated, white epithelial lesions. The denser white lesions could be removed easily after gentle swabbing, and most epithelium remained intact. The 10 cases with positive polymerase chain reaction results were all identified to be Vittaforma corneae. The mean number of corneal swabbing was 3.3, and the mean disease resolution time was 6.6 days. No patients had recurrence or loss of visual acuity at last follow-up. CONCLUSIONS Repeated swabbing effectively can eradicate corneal epithelial microsporidial lesions in approximately 1 week. It is easy to perform, less painful, and more acceptable for the patients.
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Affiliation(s)
- Nai-Wen Fan
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
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Abstract
The purpose of this paper was to analyse the causes, pathogenesis, diagnostic modalities and treatment outcomes of microsporidial keratoconjunctivitis (MKC). Microsporidia are increasingly recognized as opportunistic infectious pathogens in immunocompromized patients causing keratoconjunctivitis. In the recent years, there has been a surge in reports of MKC in immunocompetent individuals presenting with stromal keratitis. A detailed literature search was done using Medline, OVID, Cochrane Library, UptoDate and Google Scholar databases with the terms microsporidia, keratitis, conjunctivitis, immunocompromized and immunocompetent. The articles were reviewed to determine the spectrum of clinical presentation, disease course, investigations, treatment modalities and outcome. Thirty-six publications were reviewed, and 151 cases of MKC were included for this review. The main presenting features included pain, redness, photophobia, epiphora and blurring of vision. Duration of the symptoms lasted between 4 days and 18 months. Light microscopy with modified trichrome stain was most commonly used to diagnose MKC. Resolution of symptoms was most commonly achieved with oral albendazole and/or topical fumidil B. Topical fluoroquinolones are also effective as a monotherapy as suggested by recent studies. Clinical outcome was good (visual acuity ≤ 6/12) for the patients who presented earlier (≤1 month) (75% of cases with documented final best-corrected visual acuity). MKC occurs more commonly in immunocompetent individuals than expected and can be diagnosed in earlier stages. From our review, we conclude that the patients, who were diagnosed early and treated, had complete resolution of symptoms with a better clinical outcome.
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Affiliation(s)
- Alex Chengyao Tham
- Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Yishun, Singapore
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28
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Thomas KE, Purcell TL, Tanzer DJ, Schanzlin DJ. Delayed diagnosis of microsporidial stromal keratitis: unusual Wessely ring presentation and partial treatment with medications against Acanthamoeba. BMJ Case Rep 2011; 2011:2011/feb24_1/bcr0820103233. [PMID: 22707574 DOI: 10.1136/bcr.08.2010.3233] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The authors report a case of an immunocompetent 38-year-old male who presented with an indolent keratitis that eluded diagnosis after multiple cultures taken over 9 months. He was started initially on medications against Acanthamoeba, after presenting with a nearly complete corneal ring 2 months after trauma. These medications likely partially treated his condition, thereby making laboratory diagnosis more difficult. He was identified as having Encephalitozoon hellum by PCR. The patient subsequently underwent cornea transplant after a full course of medical treatment and recovered best-corrected visual acuity of 20/20.
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Affiliation(s)
- Karin E Thomas
- Department of Ophthalmology, UCSD, La Jolla, California, USA.
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29
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Practical Ophthalmic Microbiology for the Detection of Corneal Pathogens. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00018-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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30
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Sharma S, Das S, Joseph J, Vemuganti GK, Murthy S. Microsporidial Keratitis: Need for Increased Awareness. Surv Ophthalmol 2011; 56:1-22. [DOI: 10.1016/j.survophthal.2010.03.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Revised: 03/24/2010] [Accepted: 03/30/2010] [Indexed: 12/24/2022]
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Barratt JLN, Harkness J, Marriott D, Ellis JT, Stark D. Importance of nonenteric protozoan infections in immunocompromised people. Clin Microbiol Rev 2010; 23:795-836. [PMID: 20930074 PMCID: PMC2952979 DOI: 10.1128/cmr.00001-10] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
There are many neglected nonenteric protozoa able to cause serious morbidity and mortality in humans, particularly in the developing world. Diseases caused by certain protozoa are often more severe in the presence of HIV. While information regarding neglected tropical diseases caused by trypanosomatids and Plasmodium is abundant, these protozoa are often not a first consideration in Western countries where they are not endemic. As such, diagnostics may not be available in these regions. Due to global travel and immigration, this has become an increasing problem. Inversely, in certain parts of the world (particularly sub-Saharan Africa), the HIV problem is so severe that diseases like microsporidiosis and toxoplasmosis are common. In Western countries, due to the availability of highly active antiretroviral therapy (HAART), these diseases are infrequently encountered. While free-living amoebae are rarely encountered in a clinical setting, when infections do occur, they are often fatal. Rapid diagnosis and treatment are essential to the survival of patients infected with these organisms. This paper reviews information on the diagnosis and treatment of nonenteric protozoal diseases in immunocompromised people, with a focus on patients infected with HIV. The nonenteric microsporidia, some trypanosomatids, Toxoplasma spp., Neospora spp., some free-living amoebae, Plasmodium spp., and Babesia spp. are discussed.
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Affiliation(s)
- J L N Barratt
- Department of Microbiology, St. Vincent's Hospital, Darlinghurst 2010, NSW, Australia.
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33
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McLeod SD. Parasitic Keratitis. Ophthalmology 2009. [DOI: 10.1016/b978-0-323-04332-8.00038-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Analysis of the beta-tubulin gene from Vittaforma corneae suggests benzimidazole resistance. Antimicrob Agents Chemother 2007; 52:790-3. [PMID: 18056284 DOI: 10.1128/aac.00928-07] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We amplified, cloned, and sequenced the beta-tubulin gene of Vittaforma corneae, a microsporidium causing human infections. The beta-tubulin gene sequence has a substitution at Glu(198) (with glutamine), which is one of six amino acids reported to be associated with benzimidazole sensitivity. Benzimidazoles were assayed for antimicrosporidial activity and showed poor parasite inhibition.
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Sagoo MS, Mehta JS, Hau S, Irion LD, Curry A, Bonshek RE, Tuft SJ. Microsporidium Stromal Keratitis: In Vivo Confocal Findings. Cornea 2007; 26:870-3. [PMID: 17667626 DOI: 10.1097/ico.0b013e31806c7a3c] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To relate the clinical signs, histopathologic features, and in vivo confocal biomicroscopy findings of a case of stromal microsporidial keratitis and to describe the use of in vivo confocal microscopy to monitor treatment effect. METHODS An immunocompetent male patient presented with unilateral indolent stromal keratitis. Stromal microsporidiosis was confirmed after corneal biopsy. He underwent examination that used in vivo confocal microscopy (Heidelberg Retina Tomograph II and Rostock Cornea Module) before and after treatment with topical fumagillin and oral albendazole. Clinicopathologic correlation of the confocal scan was performed. RESULTS Corneal biopsy showed extracellular microsporidium spores aligned along keratocytes and corneal lamellae. In vivo confocal scans showed similar morphology, with bright dots aligned along keratocytes. Treatment with antimicrobials and topical steroid gave resolution of active keratitis, correlating with disappearance of the bright spores on repeat in vivo confocal scanning. CONCLUSIONS The in vivo confocal microscopy appearance of microsporidial keratitis corresponds to the histologic features from biopsy material. Treatment response may be monitored by using this technique, although definitive diagnosis requires corneal biopsy.
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Affiliation(s)
- Mandeep S Sagoo
- Cornea and External Diseases Service, Moorfields Eye Hospital, London, UK.
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Jeng BH, Holland GN, Lowder CY, Deegan WF, Raizman MB, Meisler DM. Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease. Surv Ophthalmol 2007; 52:329-68. [PMID: 17574062 DOI: 10.1016/j.survophthal.2007.04.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.
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Affiliation(s)
- Bennie H Jeng
- The Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Pariyakanok L, Jongwutiwes S. Keratitis caused by Trachipleistophora anthropopthera. J Infect 2005; 51:325-8. [PMID: 16291286 DOI: 10.1016/j.jinf.2004.08.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2004] [Indexed: 11/19/2022]
Abstract
We report a case of intrastromal keratitis in a 42-year-old male with underlying human immunodeficiency virus-1 infection. Numerous microsporidial spores were found from corneal biopsy. Ultrastructural studies of corneal tissues revealed dimorphic sporophorous vesicles containing characteristic spores belonging to Trachipleistophora anthropopthera. Infection could be controlled by penetrating keratoplasty but not by topical fumagillin and systemic albendazole per se. This is the first report of human keratitis caused by this organism.
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Affiliation(s)
- Lalida Pariyakanok
- Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Rama 4, Bangkok 10330, Thailand
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Vemuganti GK, Garg P, Sharma S, Joseph J, Gopinathan U, Singh S. Is microsporidial keratitis an emerging cause of stromal keratitis? A case series study. BMC Ophthalmol 2005; 5:19. [PMID: 16105181 PMCID: PMC1200253 DOI: 10.1186/1471-2415-5-19] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2005] [Accepted: 08/17/2005] [Indexed: 11/10/2022] Open
Abstract
Background Microsporidial keratitis is a rare cause of stromal keratitis. We present a series of five cases of microsporidial keratitis from a single centre in southern India with microbiologic and histopathologic features. Case presentation Patient charts of five cases of microsporidial stromal keratitis diagnosed between January 2002 and June 2004 were reviewed retrospectively for clinical data, microbiologic and histopathologic data. The presence of microsporidia was confirmed by special stains on corneal scrapings and/or corneal tissues, and electron microscopy. All patients were immunocompetent with a preceding history of trauma in three. Four patients presented with unilateral, small, persisting deep stromal infiltrates, of uncertain etiology, in the cornea, which were not responding to conventional antimicrobial treatment and required penetrating keratoplasty in three. Fifth case was unsuspected and underwent keratoplasty for post-traumatic scar. Three of five cases were diagnosed on corneal scrapings, prior to keratoplasty, while two were diagnosed only on histology. The microsporidia appeared as oval well defined bodies with dense staining at one pole. None of the patients showed recurrence following keratoplasty. Conclusion Microsporidia, though rare, should be suspected in chronic culture-negative stromal keratitis. Organisms could lie dormant without associated inflammation.
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Affiliation(s)
- Geeta K Vemuganti
- Ophthalmic Pathology Service, L.V. Prasad Eye Institute, Hyderabad, India
| | - Prashant Garg
- Cornea Service, L.V. Prasad Eye Institute, Hyderabad, India
| | - Savitri Sharma
- Jhaveri Microbiology Centre, L.V. Prasad Eye Institute, Hyderabad, India
| | - Joveeta Joseph
- Jhaveri Microbiology Centre, L.V. Prasad Eye Institute, Hyderabad, India
| | - Usha Gopinathan
- Jhaveri Microbiology Centre, L.V. Prasad Eye Institute, Hyderabad, India
| | - Shashi Singh
- Centre for Cellular and Molecular Biology, Hyderabad, India
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Visvesvara GS, Moura H, Leitch GJ, Schwartz DA, Xiao LX. Public health importance of Brachiola algerae (Microsporidia)--an emerging pathogen of humans. Folia Parasitol (Praha) 2005; 52:83-94. [PMID: 16004367 DOI: 10.14411/fp.2005.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Brachiola algerae, a parasite of Anopheles mosquitoes, has also been isolated from a human cornea, a cutaneous nodule and deep muscle tissue. All three human isolates of B. algerae are morphologically, serologically, and genetically similar to the mosquito-derived isolates including the original isolate of Vavra and Undeen. All of these isolates grew well in mammalian cell cultures at 37 degrees C and produced spores. Transmission electron microscopy revealed that all developmental stages including meronts, sporoblasts and spores were diplokaryotic and developed in direct contact with the host cell cytoplasm, a feature characteristic of the genus Brachiola. Spores of all isolates reacted well, in the immunofluorescence assay, with the rabbit anti-B. algerae serum. In the immunoblot assay, although the overall banding patterns of the human and mosquito isolates were similar, minor differences could be discerned. Sequencing of the PCR products of the amplified SSU rRNA gene revealed the existence of two distinct genotypes; the original mosquito (Undeen) isolate belonged to genotype 1 and the isolate from cornea and that from the deep muscle biopsy to genotype 2, whereas the isolates from a mosquito and one of the other two human isolates (one from skin abscess) had both genotypes, 1 and 2. It is known that spores of mosquito-derived B. algerae can not only proliferate in mammalian cell cultures at 37 degrees C but also can infect mice when injected into footpads or deposited on the corneal surface. These observations indicate that the spores have potential to be a risk factor for humans, especially those with immunodeficiency.
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Affiliation(s)
- Govinda S Visvesvara
- Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, Department of Health and Human Services, Atlanta, Georgia 30341-3724, USA.
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Tong L, Tan DTH, Abańo JM, Lim L. Deep anterior lamellar keratoplasty in a patient with descemetocele following gonococcal keratitis. Am J Ophthalmol 2004; 138:506-7. [PMID: 15364250 DOI: 10.1016/j.ajo.2004.04.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2004] [Accepted: 04/12/2004] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe the presentation and subsequent management of a case of severe gonococcal keratitis in a young man. DESIGN Case report. METHODS A young man presented with severe gonococcal keratitis. Topical and systemic antibiotics were given with no improvement, and progressive corneal melting was noted. Deep lamellar keratoplasty was performed. The clarity and state of corneal graft and the postoperative visual acuity were noted. RESULTS At 6 months posttreatment, the graft was clear, and no recurrence of infection was noticed. Corrected visual acuity was 20/25. CONCLUSION Deep lamellar keratoplasty should be considered as a therapeutic option in patients with severe gonococcal keratitis that does not respond to antibiotic treatment.
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Affiliation(s)
- Louis Tong
- Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751
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Rauz S, Tuft S, Dart JKG, Bonshek R, Luthert P, Curry A. Ultrastructural examination of two cases of stromal microsporidial keratitis. J Med Microbiol 2004; 53:775-781. [PMID: 15272065 DOI: 10.1099/jmm.0.45524-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Two cases with chronic stromal keratitis are described in immunocompetent hosts where the diagnosis was originally thought to be herpetic or adenoviral disease. Light microscopy and ultrastructural examination of corneal tissue by electron microscopy were performed following penetrating keratoplasty (case 1) and corneal biopsy (case 2). Specimens from both cases were analysed for viral identification by PCR. Two different species of Microsporidia were identified. Case 1 represents the fourth reported case of corneal stromal Vittaforma corneae where the spores measured 3.3 x 1.4 microm, arranged in characteristic linear groups of about four to eight. Each spore contained a diplokaryotic nucleus and a single row of ten polar tube coils. By contrast, case 2 is the first reported case of stromal keratitis caused by Trachipleistophora hominis. In this case, spores measured 4 x 2.4 microm, located typically within packets. In this species, the polar tube was arranged as a single row of about 10-13 profiles. Viral DNA could not be amplified by PCR. In conclusion, microsporidial stromal keratitis should be considered in culture-negative cases refractory to medical therapy. As microbiological culture techniques are unsuccessful, diagnosis may only be established following histopathological and ultrastructural examination of corneal tissue.
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Affiliation(s)
- Saaeha Rauz
- Corneal and External Diseases Service, Moorfields Eye Hospital NHS Trust, City Road, London EC1V 2PD, UK 2,3Department of Histopathology2 and Health Protection Agency3, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WZ, UK
| | - Stephen Tuft
- Corneal and External Diseases Service, Moorfields Eye Hospital NHS Trust, City Road, London EC1V 2PD, UK 2,3Department of Histopathology2 and Health Protection Agency3, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WZ, UK
| | - John K G Dart
- Corneal and External Diseases Service, Moorfields Eye Hospital NHS Trust, City Road, London EC1V 2PD, UK 2,3Department of Histopathology2 and Health Protection Agency3, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WZ, UK
| | - Richard Bonshek
- Corneal and External Diseases Service, Moorfields Eye Hospital NHS Trust, City Road, London EC1V 2PD, UK 2,3Department of Histopathology2 and Health Protection Agency3, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WZ, UK
| | - Philip Luthert
- Corneal and External Diseases Service, Moorfields Eye Hospital NHS Trust, City Road, London EC1V 2PD, UK 2,3Department of Histopathology2 and Health Protection Agency3, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WZ, UK
| | - Alan Curry
- Corneal and External Diseases Service, Moorfields Eye Hospital NHS Trust, City Road, London EC1V 2PD, UK 2,3Department of Histopathology2 and Health Protection Agency3, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WZ, UK
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Lewis NL, Francis IC, Hawkins GS, Coroneo MT. Bilateral microsporidial keratoconjunctivitis in an immunocompetent non-contact lens wearer. Cornea 2003; 22:374-6. [PMID: 12792484 DOI: 10.1097/00003226-200305000-00018] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe an immunocompetent male with bilateral microsporidial keratoconjunctivitis who responded to treatment with albendazole, propamidine, and fumagillin. METHODS Corneal and conjunctival epithelial scrapings from a man with bilateral keratoconjunctivitis previously treated with topical corticosteroids were evaluated by Gram stain and by fluorescence microscopy. RESULTS Gram stain and fluorescence microscopy of corneal epithelial scraping revealed organisms characteristic of microsporidia. Results of human immunodeficiency virus antibody testing were reported as nonreactive. Symptoms of ocular discomfort and clinical signs of keratoconjunctivitis resolved after five weeks of treatment that included systemic albendazole and topical propamidine isethionate 0.1% and fumagillin bicyclohexylammonium salt. A follow-up conjunctival scraping failed to detect any residual organisms 2 weeks after cessation of all treatment. CONCLUSION Microsporidial ocular infection occurred in an immunocompetent non-contact lens wearer. Microsporidial keratoconjunctivitis should be considered in any individual with atypical multifocal diffuse epithelial keratitis, regardless of immune status or recent history of contact lens wear.
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Affiliation(s)
- Noni L Lewis
- Department of Opthalmology, The Prince of Wales Hospital, University of New South Wales, Randwick, Sydney.
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Abstract
Microsporidia are ubiquitous organisms that are emerging pathogens in humans. These are most likely zoonotic and/or waterborne infections. In the immunosuppressed host, such as those treated with immunosuppressive drugs or infected with human immunodeficiency virus particularly at advanced stages of the disease, microsporidia can produce a wide range of clinical diseases. The most common manifestation is gastrointestinal tract infection; however, encephalitis, ocular infection, sinusitis, myositis and disseminated infection have also been described. In addition, these organisms have been reported in immune competent individuals. Multiple genera are involved in these infections and different organisms can result in distinct clinical pictures. Differences in clinical and parasitologic response to various therapeutic agents have emerged from clinical, as well as in vitro and in vivo studies. Currently there are no precisely defined guidelines for the optimal treatment of microsporidial infections. This article reviews the available data on compounds with in vitro activity and/or in vivo efficacy for microsporidial infections. Copyright 2000 Harcourt Publishers Ltd.
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Affiliation(s)
- Sylvia F. Costa
- Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine, Bronx, New York, USA
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