1
|
Dutta A, Das S, Priyadarshini SR, Mishra DK. Microbial keratitis in lattice corneal dystrophy: microsporidia as a new cause. BMJ Case Rep 2023; 16:e255143. [PMID: 38114293 DOI: 10.1136/bcr-2023-255143] [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] [Indexed: 12/21/2023] Open
Abstract
A patient in his sixth decade presented to us with redness, pain and a deterioration of vision in his left eye. He had previously been diagnosed with lattice corneal dystrophy (LCD). He was diagnosed with microbial keratitis, and mixed infection was confirmed on culture (bacteria and fungus) with a protracted healing period before resolution of keratitis. He presented 2 years later with similar issues in the same eye and was noted to have a second episode of microbial keratitis, with microsporidia spores noted on gram, potassium hydroxide and calcofluor white stains. He was diagnosed with microsporidial stromal keratitis and underwent therapeutic penetrating keratoplasty. Unfortunately, he suffered a recurrence of microsporidial keratitis following surgery with eventual transplant failure. Microsporidia as an infection in LCD has, to our knowledge, not been previously reported. We aim to discuss microsporidial infection and recurrent microbial keratitis in the setting of LCD.
Collapse
Affiliation(s)
- Anirban Dutta
- Cornea & Anterior Segment Services, LV Prasad Eye Institute Bhubaneswar Campus, Bhubaneswar, Odisha, India
- Cornea Services, Chirag Eye Care, Prayagraj, Uttar Pradesh, India
| | - Sujata Das
- Cornea & Anterior Segment Services, LV Prasad Eye Institute Bhubaneswar Campus, Bhubaneswar, Odisha, India
| | - Smruti Rekha Priyadarshini
- Cornea & Anterior Segment Services, LV Prasad Eye Institute Bhubaneswar Campus, Bhubaneswar, Odisha, India
| | - Dilip K Mishra
- Ophthalmic Pathology Laboratory, LV Prasad Eye Institute, Hyderabad, Telangana, India
| |
Collapse
|
2
|
Spena R, Bovone C, Ciarmatori N, Pellegrini M, Yu AC, Zauli G, Busin M. Microsporidial Stromal Keratitis in Post-Keratoplasty Eyes. J Clin Med 2023; 12:jcm12113706. [PMID: 37297901 DOI: 10.3390/jcm12113706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
PURPOSE The purpose of this paper is to report the clinical manifestations, diagnostic evaluation, management and outcomes of microsporidial keratitis in post-keratoplasty eyes. METHODS This is a retrospective review of three patients diagnosed with microsporidial stromal keratitis in post-keratoplasty eyes between January 2012 and December 2021 at a tertiary referral center (Ospedali Privati Forlì "Villa Igea", Forlì, Italy). RESULTS All patients presented with fine multifocal granular infiltrates following keratoplasty for a presumed herpetic keratitis. No microorganisms were isolated from the corneal scrapings and no clinical response was observed with broad-spectrum antimicrobial therapy. In all cases, confocal microscopy demonstrated spore-like structures. The histopathologic examination of the excised corneal buttons confirmed the diagnosis of microsporidial stromal keratitis. Following therapeutic keratoplasty and treatment with an initial high dose and extended taper of topical fumagillin, clinical resolution was achieved in all eyes. The Snellen visual acuities at the final follow-up were 20/50, 20/63 and 20/32. CONCLUSIONS Prior to definitive surgery, confocal microscopy can be employed for the in vivo detection of pathogenic microorganisms such as Microsporidium. In post-keratoplasty eyes, therapeutic keratoplasty and an initial high dose of topical fumagillin with extended taper can allow the resolution of microsporidial stromal keratitis with a satisfactory visual prognosis.
Collapse
Affiliation(s)
- Rossella Spena
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| | - Cristina Bovone
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
- Department of Environmental Sciences and Prevention, University of Ferrara, 44122 Ferrara, Italy
| | - Nicolò Ciarmatori
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| | - Marco Pellegrini
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| | - Angeli Christy Yu
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| | - Giorgio Zauli
- Research Department, King Khaled Eye Specialist Hospital, Riyadh 11462, Saudi Arabia
| | - Massimo Busin
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| |
Collapse
|
3
|
Mohanty A, Sahu SK, Sharma S, Mittal R, Behera HS, Das S, Lakhmipathy M. Past, present, and prospects in microsporidial keratoconjunctivitis- A review. Ocul Surf 2023; 28:364-377. [PMID: 34419638 DOI: 10.1016/j.jtos.2021.08.008] [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] [Received: 03/30/2021] [Revised: 07/19/2021] [Accepted: 08/14/2021] [Indexed: 11/29/2022]
Abstract
Ocular microsporidiosis comprises two entirely different spectra of disease as keratoconjunctivitis and stromal keratitis. Microsporidial keratoconjunctivitis (MKC) has been increasingly reported in the past two decades, probably due to raised awareness, simpler diagnostic procedures, and a better understanding of the clinical presentation. It is characterized by the presence of raised, coarse, punctate, multifocal, round to oval, greyish-white corneal epithelial lesions which usually evolve into nummular scars before resolution. Conjunctivitis seen is non-purulent and of mild-moderate intensity, with mixed papillary-follicular reaction. The mode of transmission and pathogenesis is poorly understood. Despite lack of inflammatory response, uncommon associations reported were- endotheliitis, corneal edema, limbitis, uveitis, and sub-epithelial infiltrates. There has been no consensus on the management of MKC. It varies from the use of multiple antimicrobial agents to simple lubricants. The majority of the disease goes underdiagnosed or misdiagnosed and treated as adenoviral keratoconjunctivitis, with topical steroids or anti-virals empirically. Changing trends have been noticed in the pattern of infection, possibly with increasing evidence of Vittaforma corneae as causative organisms, previously reported to cause stromal keratitis. An elaborate review of the past and present literature on MKC is provided in this review article, along with gaps in knowledge, and future directions of research.
Collapse
Affiliation(s)
- Amrita Mohanty
- Cornea and Anterior Segment Services, L. V. Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar, Odisha, India
| | - Srikant K Sahu
- Cornea and Anterior Segment Services, L. V. Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar, Odisha, India.
| | - Savitri Sharma
- Jhaveri Microbiology Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India
| | - Ruchi Mittal
- Kanupriya Dalmia Ophthalmic Pathology Laboratory, L.V. Prasad Eye Institute, Bhubaneswar, Odisha, India; Department of Pathology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Himansu Sekhar Behera
- Ocular Microbiology Service, L.V. Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar, Odisha, India
| | - Sujata Das
- Cornea and Anterior Segment Services, L. V. Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar, Odisha, India
| | - Meena Lakhmipathy
- Department of Cornea and Refractive Surgery, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| |
Collapse
|
4
|
Ward MS, Hastings JP, Shmunes KM, Ronquillo Y, Hoopes PC, Moshirfar M. Atypical presentation of acanthamoeba keratitis resembling central toxic keratopathy. Am J Ophthalmol Case Rep 2022; 25:101243. [PMID: 35028488 PMCID: PMC8715135 DOI: 10.1016/j.ajoc.2021.101243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 08/25/2021] [Accepted: 12/13/2021] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To describe an atypical case of acanthamoeba keratitis with positive in vivo confocal microscopy in a non-contact lens user who presented with signs and symptoms suggestive of central toxic keratopathy. OBSERVATIONS The patient presented with bilateral, though sequential, decreased visual acuity with mild pain. Examination showed stromal haze with corneal flattening and thinning without epithelial defects. Optical coherence tonometry of the right eye revealed an inverse dome-shaped appearance of the opacity and in-vivo confocal imaging showed double-walled cysts consistent with acanthamoeba. Corneal haze, stromal loss, resolved and visual acuity improved over time. CONCLUSION AND IMPORTANCE Acanthamoeba is a rare cause of infectious keratitis that is most often associated with contact lens wear in developed countries. Typically, it presents with a unilateral decrease in visual acuity, photophobia, watering, and pain that is out of proportion to slit lamp examination findings. However, many atypical presentations have been reported in the literature. Consequently, it may be misdiagnosed, especially early in the course of the disease. This delay in diagnosis can lead to progressive ulceration and visual impairment. In addition, cyst formation can make eradication with anti-amoebic treatment especially difficult.Central toxic keratopathy is a non-inflammatory clinical syndrome of unknown etiology that is most often associated with excimer laser ablation, though other associated causes have been reported. It is characterized by a central or paracentral opacity with corneal stromal loss and resultant hyperopic shift. The opacification and stromal loss mostly resolve over the course of months with an improvement in visual acuity. This report may help physicians broaden their differential and correctly diagnose atypical presentations of amoebic infection.
Collapse
Affiliation(s)
| | - Jordan P. Hastings
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | | | | | | | - Majid Moshirfar
- Hoopes Vision Research Center, Draper, UT, USA
- John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA
- Utah Lions Eye Bank, Murray, UT, USA
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Ledbetter EC. Applications of in vivo confocal microscopy in the management of infectious keratitis in veterinary ophthalmology. Vet Ophthalmol 2021; 25 Suppl 1:5-16. [PMID: 34480385 DOI: 10.1111/vop.12928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/06/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
In vivo confocal microscopy (IVCM) is a relatively new ocular imaging technique that permits morphological and quantitative assessment of the living cornea on the cellular level. The applications for IVCM in clinical ophthalmology are numerous and diverse. There are several advantages inherent to IVCM over standard diagnostic techniques currently used to confirm a diagnosis of infectious keratitis in veterinary ophthalmology. With IVCM, images can be viewed in real-time providing immediate diagnostic information. Traumatic corneal sampling techniques are avoided, and the procedure can be repeated as frequently as is clinically indicated without risk of corneal tissue damage. Both superficial and deep corneal lesions can be evaluated by IVCM in an atraumatic fashion. Microorganism viability is not required for their detection and specialized diagnostic laboratory assay procedures are not necessary. Many larger infectious agents can be directly identified within corneal lesions by IVCM, including fungi and parasites such as Acanthamoeba spp. In other situations, such as bacterial infectious crystalline keratopathy, the biological systems associated with the microorganism can be detected within the cornea. The current resolution of IVCM is inadequate to directly visualize some corneal infectious agents, such as herpesviruses, but host responses and virus-infected epithelial cells can be identified. This review summarizes the current knowledge and applications of IVCM in the management of infectious keratitis in veterinary ophthalmology, including its use in animals with bacterial, fungal, parasitic, and viral keratitis.
Collapse
Affiliation(s)
- Eric C Ledbetter
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| |
Collapse
|
8
|
Hoarau G, Merabet L, Knoeri J, Georgeon C, Poirier P, Borderie V, Brignole-Baudouin F, Bouheraoua N. Microsporidial keratoconjunctivitis: Report of two imported cases. J Fr Ophtalmol 2021; 44:e551-e554. [PMID: 34148704 DOI: 10.1016/j.jfo.2020.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022]
Affiliation(s)
- G Hoarau
- CHNO des Quinze-Vingts, Inserm-DGOS CIC 1423, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France
| | - L Merabet
- CHNO des Quinze-Vingts, Inserm-DGOS CIC 1423, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France
| | - J Knoeri
- CHNO des Quinze-Vingts, Inserm-DGOS CIC 1423, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France
| | - C Georgeon
- CHNO des Quinze-Vingts, Inserm-DGOS CIC 1423, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France
| | - P Poirier
- Laboratoire de parasitologie-mycologie, 3IHP, centre hospitalier universitaire Gabriel-Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France; Université Clermont-Auvergne, CNRS UMR 6023, laboratoire Micro-organismes: génome et environnement, Clermont-Ferrand, France
| | - V Borderie
- CHNO des Quinze-Vingts, Inserm-DGOS CIC 1423, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France; Sorbonne université, Inserm, CNRS, Institut de la Vision, 17, rue Moreau, 75012 Paris, France
| | - F Brignole-Baudouin
- CHNO des Quinze-Vingts, Inserm-DGOS CIC 1423, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France
| | - N Bouheraoua
- CHNO des Quinze-Vingts, Inserm-DGOS CIC 1423, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France; Sorbonne université, Inserm, CNRS, Institut de la Vision, 17, rue Moreau, 75012 Paris, France.
| |
Collapse
|
9
|
Patel DV, Zhang J, McGhee CN. In vivo confocal microscopy of the inflamed anterior segment: A review of clinical and research applications. Clin Exp Ophthalmol 2020; 47:334-345. [PMID: 30953391 DOI: 10.1111/ceo.13512] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 03/20/2019] [Accepted: 04/02/2019] [Indexed: 12/17/2022]
Abstract
In vivo confocal microscopy (IVCM) allows non-invasive imaging of the living human cornea, specifically enabling the detection of immune cells in the healthy and diseased ocular anterior segment. Studies using IVCM have provided insight into the effects of contact lens wear on corneal Langerhans cell density and morphology, and the effects of eye drops on conjunctiva-associated lymphoid tissue. IVCM has also been shown to be a useful adjunctive diagnostic tool in distinguishing infective and non-infective uveitis and in diagnosing atypical infective keratitis. In the research setting, this technology has enhanced our understanding of the role of inflammatory cells in corneal neuropathy and angiogenesis. In vivo-ex vivo correlation using animal models has helped overcome some of the difficulties in identifying cell type on IVCM images. As highlighted in this review, currently there are multiple established, and emerging, clinical and research applications for IVCM in the inflamed anterior segment.
Collapse
Affiliation(s)
- Dipika V Patel
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jie Zhang
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Charles Nj McGhee
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| |
Collapse
|
10
|
Abstract
Microsporidia are a rare and commonly misdiagnosed cause of corneal infection, accounting for approximately 0.4% of cases of microbial keratitis in some populations. Ocular microsporidiosis most often presents as either microsporidial keratoconjunctivitis (MKC) or microsporidial stromal keratitis (MSK). Though these two clinical entities exhibit similar symptomology, they are distinguished from one another by the time course for disease progression, findings on slit-lamp examination, and response to medical therapy. This review summarizes the current literature on the etiology and clinical presentation of microsporidial infections of the cornea and highlights ongoing developments in available diagnostic modalities and treatment regimens.
Collapse
|
11
|
Devi L, Prajna NV, Srinivasan M, Radhakrishnan N, Das M. Microsporidial infection masquerading as graft rejection post-Descemet's stripping automated endothelial keratoplasty. Indian J Ophthalmol 2017; 65:869-871. [PMID: 28905834 PMCID: PMC5621273 DOI: 10.4103/ijo.ijo_295_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 51-year-old immunocompetent male with a history of Fuchs' endothelial dystrophy and immature cataract who underwent Descemet's stripping automated endothelial keratoplasty with intraocular lens implantation in both eyes presented with redness and defective vision of 1-day duration in his left eye. Slit lamp examination revealed coarse superficial punctate lesions with graft edema. He was diagnosed with acute graft rejection and treated with topical steroids. Two days later, symptoms worsened in his left eye with the involvement of his right eye showing a similar clinical picture. An infectious etiology was suspected and in vivo confocal microscopy ordered, which revealed hyperreflective dots, highly suggestive of microsporidial spores. The patient was prescribed topical fluconazole 0.3% in both eyes. This unique presentation of bilateral graft edema following microsporidial keratoconjunctivitis in postgraft patients requires a high index of suspicion as it can be easily be mistaken for and mismanaged as acute graft rejection.
Collapse
Affiliation(s)
- Lumbini Devi
- Department of Cornea, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | | | | | | | - Manoranjan Das
- Department of Cornea, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Malhotra C, Jain AK, Kaur S, Dhingra D, Hemanth V, Sharma SP. In vivo confocal microscopic characteristics of microsporidial keratoconjunctivitis in immunocompetent adults. Br J Ophthalmol 2017; 101:1217-1222. [DOI: 10.1136/bjophthalmol-2016-309794] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 01/05/2017] [Accepted: 01/07/2017] [Indexed: 11/03/2022]
|
14
|
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
|
15
|
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]
|
16
|
Abstract
PURPOSE To describe the clinical features, disease course, management, and visual outcome of stromal microsporidial keratitis involving the corneal graft in an immunocompetent patient. METHODS Case report. RESULTS We report the case of a 21-year-old immunocompetent woman, who underwent penetrating keratoplasty for advanced keratoconus in her right eye and presented with features of acute graft rejection after 15 months. Standard treatment using topical and systemic steroids failed to reverse the graft rejection. A regraft was performed in that eye. Histopathology of the donor corneal button revealed microsporidiosis involving the deep stroma. CONCLUSIONS Microsporidiosis is rarely encountered in a corneal graft and masquerades as acute graft rejection. Histopathology could help in making a final diagnosis.
Collapse
|
17
|
Messmer EM. Confocal microscopy: when is it helpful to diagnose corneal and conjunctival disease? EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.3.2.177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
18
|
Kymionis GD, Diakonis VF, Shehadeh MM, Pallikaris AI, Pallikaris IG. Anterior Segment Applications of In Vivo Confocal Microscopy. Semin Ophthalmol 2013; 30:243-51. [DOI: 10.3109/08820538.2013.839817] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
19
|
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.
Collapse
Affiliation(s)
- Nai-Wen Fan
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | |
Collapse
|
20
|
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.
Collapse
Affiliation(s)
- Alex Chengyao Tham
- Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Yishun, Singapore
| | | |
Collapse
|
21
|
Abstract
Specific therapy of ocular infections often requires etiological diagnosis that is a combined effect of observation of characteristic clinical features and microbiological investigations. Clinical impression is central to guiding the laboratory investigation, and the aim of laboratory investigation is to confirm or rule out the clinical diagnosis. However, clinical features may vary considerably, and no one clinical feature may be pathognomonic of a particular pathogen. In addition, there may be a racial, geographical, and climatic difference in the distribution and type of causative agents associated with infections. Ophthalmologists have at their disposal in vivo and in vitro methods of diagnosis of ocular infections. The expertise of the clinician and the microbiologist along with the facilities available, determine the success with accurate diagnosis. A wide range of conventional and molecular techniques are available that not only provide rapid diagnosis for known common infections but have the potential to bring to the fore unknown organisms that may be associated with ocular infections.
Collapse
|
22
|
Petroll WM, Cavanagh HD, Jester JV. Confocal Microscopy. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00022-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
23
|
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]
|
24
|
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.
Collapse
Affiliation(s)
- J L N Barratt
- Department of Microbiology, St. Vincent's Hospital, Darlinghurst 2010, NSW, Australia.
| | | | | | | | | |
Collapse
|
25
|
|
26
|
Labbé A, Khammari C, Dupas B, Gabison E, Brasnu E, Labetoulle M, Baudouin C. Contribution of In Vivo Confocal Microscopy to the Diagnosis and Management of Infectious Keratitis. Ocul Surf 2009; 7:41-52. [DOI: 10.1016/s1542-0124(12)70291-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|