Swimming Pool-Associated Vittaforma-Like Microsporidia Linked to Microsporidial Keratoconjunctivitis Outbreak, Taiwan

Clinical Analyses of 4 Cases of Microsporidial Keratoconjunctivitis

OBJECTIVE

To report four cases of microsporidial keratoconjunctivitis (MKC) from The Affiliated Eye Hospital of Nanjing Medical University (from May 2023 to October 2024) and to aid ophthalmologists in diagnosing and treating MKC, as MKC has been increasingly reported in Asian healthy individuals but not much in Mainland China.

METHODS

Four patients with MKC were studied. Demographic information, symptoms, and clinical data were collected. Diagnosis involved ophthalmic examinations, corneal scraping microscopy (including Giemsa staining, modified Ziehl-Neelsen staining, Calcofour white staining), bacterial and fungal cultures, and metagenomic next-generation sequencing (mNGS). Treatment included various topical medications like polyhexamethylene biguanide (PHMB), fluconazole, tacrolimus, sodium hyaluronate, and systemic medication such as albendazole.

RESULTS

Three cases were caused by Encephalitozoon hellem proved by mNGS. Patients had symptoms like eye redness, swelling, pain, foreign body sensation, and vision loss. Risk factors included improper contact lens - wearing habits, contact with birds, or exposure to potentially contaminated environments. All patients showed improvements after treatment, with 3 cases cured and 1 case improved.

CONCLUSION

MKC is a unilateral, acute, non-purulent ocular surface infectious disease. Clinicians should be more aware of it. Diagnosis depends on recognizing clinical signs, exploring risk factors, and laboratory tests. There is no consensus on treatment, but combined topical and systemic anti-protozoal drugs showed good results. Further large-scale validation is needed. Relevant departments should strengthen water source management, and patients should pay attention to personal hygiene.

Digital PCR detection of microsporidia in household pipe water of patients with microsporidial keratitis

This is a prospective non-comparative experimental study aimed to investigate the presence of microsporidia in household pipe water of microsporidial keratitis (MK) patients and to describe the patients' characteristics and behavioral risk factors. This study was conducted at Walailak University Hospital, Thailand, from July 2022 to February 2024. Patients diagnosed with MK were surveyed using a questionnaire to assess personal behaviors and source of household water. Water from faucets of MK patients' houses were collected for laboratory analysis with digital polymerase chain reaction (dPCR) to detect microsporidia in water samples. The study involved 54 MK patients, with 23 households contributing water samples. Utilizing dPCR analysis, we found that all water samples were contaminated with microsporidia. Level of contamination differed depending on the water source, with households that use untreated water in their plumbing system having significantly higher copies of pathogenic microsporidial DNA. Contrary to traditionally perceived risk from soil contact into eyes, our study identifies household water as an unforeseen potential source of MK. This emphasizes the critical importance of water quality management in preventing the infection.

Waterborne transmission of protozoan parasites: a review of worldwide outbreaks - an update 2017-2022

The current study presents a comprehensive review of worldwide waterborne parasitic protozoan outbreaks reported between 2017 and 2022. In total, 416 outbreaks were attributed to the waterborne transmission of parasitic protozoa. Cryptosporidium accounted for 77.4% (322) of outbreaks, while Giardia was identified as the etiological agent in 17.1% (71). Toxoplasma gondii and Naegleria fowleri were the primary causes in 1.4% (6) and 1% (4) of outbreaks, respectively. Blastocystis hominis, Cyclospora cayetanensis, and Dientamoeba fragilis were independently identified in 0.72% (3) of outbreaks. Moreover, Acanthamoeba spp., Entamoeba histolytica, Vittaforma corneae, and Enterocytozoon bieneusi were independently the causal agents in 0.24% (1) of the total outbreaks. The majority of the outbreaks (195, 47%) were reported in North America. The suspected sources for 313 (75.2%) waterborne parasitic outbreaks were recreational water and/or swimming pools, accounting for 92% of the total Cryptosporidium outbreaks. Furthermore, 25.3% of the outbreaks caused by Giardia were associated with recreational water and/or swimming pools. Developing countries are most likely to be impacted by such outbreaks due to the lack of reliable monitoring strategies and water treatment processes. There is still a need for international surveillance and reporting systems concerning both waterborne diseases and water contamination with parasitic protozoa.

Metagenomic sequencing for investigation of a national keratoconjunctivitis outbreak, Israel, 2022

BackgroundEpidemics of keratoconjunctivitis may involve various aetiological agents. Microsporidia are an uncommon difficult-to-diagnose cause of such outbreaks.AimDuring the third quarter of 2022, a keratoconjunctivitis outbreak was reported across Israel, related to common water exposure to the Sea of Galilee. We report a comprehensive diagnostic approach that identified Vittaforma corneae as the aetiology, serving as proof of concept for using real-time metagenomics for outbreak investigation.MethodsCorneal scraping samples from a clinical case were subjected to standard microbiological testing. Samples were tested by calcofluor white staining and metagenomic short-read sequencing. We analysed the metagenome for taxonomical assignment and isolation of metagenome-assembled genome (MAG). Targets for a novel PCR were identified, and the assay was applied to clinical and environmental samples and confirmed by long-read metagenomic sequencing.ResultsFluorescent microscopy was suggestive of microsporidiosis. The most abundant species (96.5%) on metagenomics analysis was V. corneae. Annotation of the MAG confirmed the species assignment. A unique PCR target in the microsporidian rRNA gene was identified and validated against the clinical sample. The assay and metagenomic sequencing confirmed V. corneae in an environmental sludge sample collected at the exposure site.ConclusionsThe real-time utilisation of metagenomics allowed species detection and development of diagnostic tools, which aided in outbreak source tracking and can be applied for future cases. Metagenomics allows a fully culture-independent investigation and is an important modality for public health microbiology.

Global prevalence and genotype distribution of Microsporidia spp. in various consumables: a systematic review and meta-analysis

Water and food sources play a major role in the distribution and transfer of microsporidia infection to animals and humans. So, this systematic review and meta-analysis aimed to assess the status and genetic diversity of microsporidia infection in water, vegetables, fruits, milk, cheese, and meat. The standard protocol of Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was followed. Scopus, PubMed, Web of Science, and Google Scholar were searched from 1 January 2000 and 1 February 2023. The point estimates and 95% confidence intervals (CIs) were calculated using a random-effects model. Of the 1,308 retrieved studies, 35 articles were included in the final meta-analysis. The pooled prevalence of microsporidia infection in mixed water, mixed fruits, mixed vegetables, and milk was 43.3% (95% CI, 33-54.2%; I², 94.86%), 35.8% (95% CI, 5.3-84.8%; I², 0), 12% (95% CI, 4.9-26.6%; I², 96.43%), and 5.8% (95% CI, 2.7-12%; I², 83.72%), respectively. Considering the genotypes, microsporidia with genotype D in water sources and genotype CD6 in vegetables/fruits were the highest reported genotypes. Given the relatively high prevalence of microsporidiosis (especially in water sources), designing strategies for control, and prevention of microsporidia infection in these sources should be recommended.

Past, present, and prospects in microsporidial keratoconjunctivitis- A review

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.

Evaluation of phoxim toxicity on aquatic and zebrafish intestinal microbiota by metagenomics and 16S rRNA gene sequencing analysis

Phoxim is one of the main organophosphorus pesticides used in agricultural production. However, little information is known about how it affects the aquatic microbial community and the intestinal microbiota of fish. Herein, we utilized shotgun metagenomics and 16S rRNA gene sequencing to reveal the aquatic eco-risk of phoxim. Seven days of phoxim exposure significantly changed the composition of aquatic microbial community, obliterated the interactions between microorganisms, and thus reduced the complexity and stability of the microbial community. During long-time exposure (i.e., 14 days), most of the ecological functions were restored due to the redundancy of the microbial community. However, phoxim exposure promoted the dissemination of elfamycin resistance gene. The zebrafish gut microbial community also recovered from a temporary ecological disorder of aquatic microbiota, but phoxim continually affected zebrafish growth and swimming behavior. Overall, our results demonstrated that phoxim exposure significantly changed the structure and function of the microbial community and displayed a negative impact on freshwater ecosystems in a short exposure time.

Practical Guidance for Clinical Microbiology Laboratories: Diagnosis of Ocular Infections

The variety and complexity of ocular infections have increased significantly in the last decade since the publication of Cumitech 13B, Laboratory Diagnosis of Ocular Infections (L. D. Gray, P. H. Gilligan, and W. C. Fowler, Cumitech 13B, Laboratory Diagnosis of Ocular Infections, 2010). The purpose of this practical guidance document is to review, for individuals working in clinical microbiology laboratories, current tools used in the laboratory diagnosis of ocular infections. This document begins by describing the complex, delicate anatomy of the eye, which often leads to limitations in specimen quantity, requiring a close working bond between laboratorians and ophthalmologists to ensure high-quality diagnostic care. Descriptions are provided of common ocular infections in developed nations and neglected ocular infections seen in developing nations. Subsequently, preanalytic, analytic, and postanalytic aspects of laboratory diagnosis and antimicrobial susceptibility testing are explored in depth.