Recurrent corneal infections in a patient with the acquired immunodeficiency syndrome

Enhancing Clinical Decision-Making in Complex Corneal Disorders: The Role of In-Vivo Confocal Microscopy

This study aims to describe how in-vivo confocal microscopy (ICVM) results improved diagnosis and treatment in three patients with complex corneal disorders at a single institution. Case one was a 36-year-old woman contact lens wearer referred to the hospital eye service (HES) by her community optician for a suspected corneal ulcer in her left eye. The case demonstrated that where laboratory cell culture was inconclusive, IVCM imaging improved diagnosis and more importantly adjusted the initial treatment till the complete resolution of the case. Case two was a shared-care 66-year-old keratoconus patient under a complex immunosuppression regime who had developed a recent series of post-surgical complications of fungal origin and was experiencing eye pain. IVCM was able to differentiate between an immune-mediated response and fungal keratitis and guide the clinicians towards an optimized treatment. Case three was a long-standing dry eye disease in a 64-year-old woman diagnosed with primary Sjögren’s syndrome where previous treatments failed to improve her symptomatology. IVCM was crucial for prescribing allogeneic serum eyedrops by anticipating early immune changes in the sub-basal corneal nerve plexus. In-vivo confocal microscopy can be an essential non-invasive imaging technique for improving clinicians’ diagnostic precision by adding a layer of certainty that other techniques may lack. Additionally, IVCM allows adjustment of the treatment accordingly, by instantly following any pathologic changes at the cellular level.

Herpes zoster ophthalmicus: disease spectrum in young adults

Purpose:

To establish the clinical profile of herpes zoster ophthalmicus (HZO) in adults younger than 40 years and correlate the clinical manifestation with their immune status.

Materials and Methods:

A retrospective chart review was performed of patients younger than 40 years who presented with HZO. Data were collected on demographics, medical history, clinical presentation, results of serological investigations, and visual outcome.

Results:

The study cohort comprised 18 subjects with a mean age of 29.7 ± 6.2 years. Ophthalmic features included lid edema, ptosis, cicatricial lid deformities, sclerokeratitis, peripheral ulcerative keratitis, neuroparalytic keratitis, keratouveitis with concomitant glaucoma, secondary bacterial keratitis and superficial punctate keratitis with dry eye, optic neuritis, and trochlear nerve palsy. Eight of 18 (44.4%) subjects were found to be positive for Human Immunodeficiency Virus (HIV). Disseminated herpetic lesions were seen present in 5 (63%) of these 8 subjects. Postherpetic neuralgia was noted in 6 (75%) of 8 HIV-positive subjects and in 1 HIV-negative patient. Final visual acuity was 20/40 or better in 90% of the immunocompetent subjects and 20/200 or worse in 100% of the HIV-positive subjects.

Conclusions:

Immunocompetent young adults do present with features of HZO. However, the disease spectrum in HIV-negative patients is localized, less severe, and more amenable to therapy as compared with young adults with HIV.

Calcineurin controls drug tolerance, hyphal growth, and virulence in Candida dubliniensis

Candida dubliniensis is an emerging pathogenic yeast species closely related to Candida albicans and frequently found colonizing or infecting the oral cavities of HIV/AIDS patients. Drug resistance during C. dubliniensis infection is common and constitutes a significant therapeutic challenge. The calcineurin inhibitor FK506 exhibits synergistic fungicidal activity with azoles or echinocandins in the fungal pathogens C. albicans, Cryptococcus neoformans, and Aspergillus fumigatus. In this study, we show that calcineurin is required for cell wall integrity and wild-type tolerance of C. dubliniensis to azoles and echinocandins; hence, these drugs are candidates for combination therapy with calcineurin inhibitors. In contrast to C. albicans, in which the roles of calcineurin and Crz1 in hyphal growth are unclear, here we show that calcineurin and Crz1 play a clearly demonstrable role in hyphal growth in response to nutrient limitation in C. dubliniensis. We further demonstrate that thigmotropism is controlled by Crz1, but not calcineurin, in C. dubliniensis. Similar to C. albicans, C. dubliniensis calcineurin enhances survival in serum. C. dubliniensis calcineurin and crz1/crz1 mutants exhibit attenuated virulence in a murine systemic infection model, likely attributable to defects in cell wall integrity, hyphal growth, and serum survival. Furthermore, we show that C. dubliniensis calcineurin mutants are unable to establish murine ocular infection or form biofilms in a rat denture model. That calcineurin is required for drug tolerance and virulence makes fungus-specific calcineurin inhibitors attractive candidates for combination therapy with azoles or echinocandins against emerging C. dubliniensis infections.

Candida albicans keratitis in an immunocompromised patient

PURPOSE

When investigating a case of unexplained corneal ulceration, we need to think of fungal infection and any predisposing factors.

METHODS

A case study of a corneal ulceration in a patient who was HIV positive with a devastating visual outcome.

RESULTS

Therapeutic corneal graft was necessary due to corneal perforation. Immunocompromised state of patient was retrospectively diagnosed.

CONCLUSIONS

Candida albicans keratitis is an opportunistic infection of a compromised cornea, and sometimes unknowingly compromised host, which can be initially misdiagnosed. Despite intensive antifungal therapy, occasionally patients require corneal grafting to improve vision, and before it is possible to establish an accurate diagnosis.

Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease

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.

Capnocytophaga keratitis. A clinicopathologic study of three patients, including electron microscopic observations

BACKGROUND

Histopathologic studies of this unusual keratitis caused by Capnocytophaga species have not been reported previously.

METHODS

The authors report the light microscopic and ultrastructural findings of three patients with a distinctive necrotizing keratitis caused by an anaerobic gram-negative bacillus. In three patients, ages 19, 81, and 91 years, a necrotizing stromal keratitis developed; two of these patients had a previous penetrating keratoplasty for pseudophakic bullous keratopathy. The first patient did not have ocular surgery previously and was treated initially for presumed Acanthamoeba keratitis.

RESULTS

By light microscopy, all three keratectomy specimens were strikingly similar and showed a necrotizing and/or suppurative stromal keratitis displaying myriad slender, fusiform, gram-negative bacilli located anterior to Descemet's membrane and extending into the deep corneal stroma, assuming a "picket fence" appearance. Cultures of the cornea in case 1 grew Capnocytophaga ochracea. For the remaining two patients, a diagnosis presumptively was made based on characteristic histopathologic features. Results of electron microscopic examination showed numerous bacilli that were mostly extracellular; occasional organisms were phagocytosed by macrophages.

CONCLUSION

The histopathologic features of Capnocytophaga keratitis are unique; therefore, a presumptive diagnosis can be made based on the morphology and location of the bacilli in the keratectomy specimens. To the authors' knowledge, this is the first study describing the typical histopathologic and electron microscopic findings of Capnocytophaga keratitis.