"Demodicosis" Mimicking PreSeptal Cellulitis: Severe Periocular and Facial Inflammation Caused by "Normal" Skin Flora

Due to their relatively high prevalence and commensalism, the pathogenicity of Demodex mites has been debated. Recent data, however, show Demodex to be associated with skin and ocular surface diseases such as rosacea, blepharitis, and keratitis. Here the authors report the first known case, to the best of the their knowledge, of Demodex infestation mimicking preseptal cellulitis in an adult human. A 29-year-old male bilaterally blind from advanced retinopathy of prematurity presented with a 2-month history of right-greater-than-left upper eyelid and periocular/cheek swelling, redness, and ocular discharge that did not resolve with oral antibiotics or oral steroids. Based on MRI findings, biopsies of the right lacrimal gland, right orbital fat, and right upper eyelid preseptal skin were obtained which revealed marked intrafollicular Demodex mite density and budding yeasts in the upper eyelid skin. This case serves to alert clinicians to this entity that may not otherwise be usually considered in ophthalmic clinical practice.

The correlation between the microstructure of meibomian glands and ocular Demodex infestation: A retrospective case-control study in a Chinese population

Meibomian gland dysfunction (MGD) is a common disease in ophthalmic clinic. This study aimed to explore ocular Demodex infestation on the microstructure changes of the meibomian glands (MGs) in patients with MGD by in vivo confocal microscopy (IVCM).We retrospectively reviewed 103 eyes of 52 patients with MGD and 62 eyes of 31 non-MGD patients. All enrolled patients underwent IVCM examination. The following IVCM parameters were recorded: the MG acinar density (MAD), MG acinar longest diameter (MALD), MG acinar shortest diameter (MASD), MG orifice area (MOA), severity of MG fibrosis (MF), MG acinar irregularity (MAI), meibum secretion reflectivity (MSR), inhomogeneous appearance of walls of acinar units (AWI) and periglandular interstices of acinar units (API), and the number of Demodex.The positive rate of Demodex infestation in MGDs was 89.32%, and statistically higher than control group (controls; P < .001). All parameters showed statistically significant differences between MGDs and controls (P < .001), and Demodex-negative group and Demodex-positive group (P < .05) in both MGDs and controls, except MAD (P = .826) in controls. The number of Demodex was positively correlated with MALD, MASD, MF, MAI, MSR, AWI, and API in MGDs and controls (P < .05), and negatively correlated with MAD and MOA in MGDs (P < .05). MOA showed a strong significant correlation with the number of Demodex in controls (P < .001), whereas there was no significant difference between the number of Demodex and the MAD in controls (P = .448).Demodex can cause microstructural changes of MGs, which can cause or aggravate MGD, and the more the number of Demodex infestation, the more serious the structural damage.

[Tick Infestation of the Eyelid: Case Report and Literature Review]

Tick infestation is rarely seen in ophthalmological practice. We report the case of a 73-year-old woman who presented with edema and erythema of her right upper eyelid. Biomicroscopic examination revealed a tick firmly attached to the eyelid margin. The tick was successfully removed using fine tweezers, and within a few days, the patient had fully recovered without sequelae. Ticks are a threat to public health as they are known vectors of numerous infectious agents responsible for serious pathologies such as Lyme disease. Ticks may also induce cutaneous local reactions, and more rarely, tick paralysis. Since morbidity increases substantially with the duration of the infestation, the tick should be completely removed as soon as possible, and patients should be aware about possible signs of tick related diseases.

Diffuse Papular Eruption of the Face and Eyelids

A 68-year-old Caucasian woman presented with a 1-month history of a facial and neck eruption (Figure 1A). Her face was covered with 3-mm monomorphic, pink, shiny, papules and rare pustules on an erythematous background. The eruption extended down the neck, her conjunctivae were injected, and her lid margins were inflamed. She had no history of rosacea.

Subcutaneous dirofilariasis of the eyelid in a 7-month-old infant

Human dirofilariasis is an unusual zoonotic infection (transmitted from animals to humans) presenting as a subcutaneous nodule. Occasionally it involves the eye. The parasite is transmitted to humans by mosquitoes. Presentation in infants is extremely rare. A rare case of subcutaneous dirofilariasis of the eyelid in a 7-month-old infant is reported.

An unusual erysipelas-like presentation

A 61-year-old man presented with erysipelas-like cutaneous leishmaniasis.

Tick infestation of the eyelid: a case report in a child

A three-year-old girl presented with a small brown lesion on the right upper eyelid margin. Close examination revealed an insect body attached to the eyelid margin. Microscopic examination of the specimen identified the species of the organism as Ixodes ricinus. The tick was completely removed with blunt forceps. She was treated with lid toilet, irrigation, and application of topical 0.3% ciprofloxacin four times daily to the affected eye. The lesion healed without scarring after one week. No systemic symptoms were observed. Mechanical removal with blunt forceps may be a quick, easy, safe and effective treatment for ticks located on the eyelids.

[Mucosal complication of cutaneous leishmaniasis]

A 74-year-old man from the rural area of Caicedonia, Valle del Cauca Province, was diagnosed with uncontrolled hypertension, stage IV chronic renal failure and severe anemia. Fifteen years earlier, while living in Guaviare Province, he was diagnosed with leishmaniasis-with lesions located on the right upper and lower eyelids, left auricle and limbs. At that time, he received an incomplete treatment with antimonials. The patient had experienced 8 years of progressive mucosal lesions located in the upper lip, nasal mucosa and right upper and lower eyelids (figure 1). A histopathological diagnosis of leishmaniasis was made and confirmed by polymerase chain reaction (figure 2). Treatment with antimonials (Glucantime) was contraindicated due to the patient's comorbidities. Inpatient supervised treatment with miltefosine (Impavido 50 mg capsules) was initiated according to the national guidelines of 1.8 mg/kg/day for 28 days. Clinical follow up and routine laboratory tests (creatinine, BUN, liver function tests and complete blood counts) were done during and after treatment; no complications were reported. Medical follow up was continued until the Internal medicine, ophthalmology, and plastic surgery consultations were provided for subsequent management of the pathology. Mucocutaneous leishmaniasis is a serious preventable complication of cutaneous leishmaniasis. This case illustrated a failure in opportune diagnosis and treatment of this disease as a consequence of an inadequate leishmaniasis control program. The case indicated the effectiveness of miltefosine as a therapeutic option in patients for whom antimonial treatment is contraindicated.

Leishmania mexicana infection of the eyelid in a traveler to Belize

A 50 year-old man, a United States resident, presented in Texas with a violaceous non-ulcerating lesion, involving the entire lower eyelid. The patient had traveled to a jungle area of Belize several hours drive from the capital city. Leishmania mexicana was isolated. The lesion only partially resolved after an initial course of sodium stibogluconate, requiring retreatment. At two years of follow-up, there was no relapse. The parasite isolated from the patient caused a progressive, non-ulcerating lesion in an experimental mouse footpad infection. This is an unusual case of cutaneous leishmaniasis in a traveler. Travelers must be educated about personal protective measures to prevent exotic infections acquired during travel.

Phthiriasis palpebrarum: a common culprit with uncommon presentation

Since infestation of the eyelashes by pubic lice is relatively uncommon, it might well be misdiagnosed as bacterial conjunctivitis, allergic contact dermatitis, or seborrheic and rosacea blepharitis. We present and graphically illustrate a case of blepharoconjunctivits attributed to P. Pubis infestation and offer further support for the use of the ophthalmologic agent 4 percent pilocarpine gel as a primary or adjunctive treatment modality.

A Case of Orbital Dirofilariasis in Northern Turkey

A 29-year-old male patient presented with complaints of a localized mass behind his right lower eyelid that had been present for the last 6 months. Ophthalmologic examination was completely normal except for a 2 cm x 2 cm painless mass localized on the inferior orbital rim behind the right lower eyelid. An excisional biopsy was planned, and an anterior orbitotomy was performed by a lateral canthotomy and inferior cantholysis. Premature rupture of the cyst occurred during dissection, disclosing a thin white parasite surrounded by copious purulent material. The parasite and surrounding cyst were submitted to laboratory for evaluation. The parasite was typed as Dirofilaria repens (13 cm, female). The patient remained symptom-free over the 4 months of postoperative follow-up. Detection of the first human case of orbital dirofilariasis in Northern Turkey, in a patient with no history of travel to any endemic areas, has raised questions about the parasite's zoonotic characteristics.

Clinical treatment of ocular demodecosis by lid scrub with tea tree oil

PURPOSE

To report clinical outcome of treating ocular demodecosis by lid scrub with tea tree oil (TTO).

METHODS

Retrospective review of clinical results in 11 patients with ocular Demodex who received weekly lid scrub with 50% TTO combined with daily lid hygiene with tea tree shampoo.

RESULTS

These 11 patients also had meibomian gland dysfunction (n = 7) manifesting abnormal lipid film with slow lipid film spread, intermittent trichiasis (n = 5), and subjective lash loss (n = 4), suggesting damage to the meibomian glands and lash follicles. In addition, conjunctival inflammation (n = 8) was associated with conjunctivitis (n = 5), conjunctivochalasis (n = 3), findings suspicious for pemphigoid (n = 2), and recurrent pterygium (n = 2). After TTO lid scrub, the Demodex count dropped to 0 for 2 consecutive visits in less than 4 weeks in 8 of 11 patients. Ten of the 11 patients showed different degrees of symptomatic relief and notable reduction of inflammatory signs. Significant visual improvement in 6 of 22 eyes was associated with a stable lipid tear film caused by significant reduction of lipid spread time. Lid scrub with 50% TTO caused notable irritation in 3 patients.

CONCLUSION

Demodex potentially causes ocular surface inflammation, meibomian gland dysfunction, and lash abnormalities. Lid scrub with TTO can effectively eradicate ocular Demodex and result in subjective and objective improvements. This preliminary positive result warrants future prospective investigation of Demodex pathogenicity.

Leishmania mexicana infection of the eyelid in a traveler to Belize

A 50 year-old man, a United States resident, presented in Texas with a violaceous non-ulcerating lesion, involving the entire lower eyelid. The patient had traveled to a jungle area of Belize several hours drive from the capital city. Leishmania mexicana was isolated. The lesion only partially resolved after an initial course of sodium stibogluconate, requiring retreatment. At two years of follow-up, there was no relapse. The parasite isolated from the patient caused a progressive, non-ulcerating lesion in an experimental mouse footpad infection. This is an unusual case of cutaneous leishmaniasis in a traveler. Travelers must be educated about personal protective measures to prevent exotic infections acquired during travel.

Periocular involvement in cutaneous leishmaniasis

OBJECTIVE

Although cutaneous leishmaniasis (CL) occurs mostly in the facial area, periocular involvement accounts for 2-5% of the facial lesions. CL lesions localized in the periocular region can easily be confused with various other diseases. The aim of this study was to examine the frequency of periocular involvement in CL in the Cukurova region of Turkey, as well as the clinical characteristics, diagnosis and methods of treatment of this disease.

METHODS

Between December 1998 and December 2004, patients who were diagnosed with CL were evaluated prospectively with respect to periocular involvement.

RESULTS

From the 2066 patients evaluated with CL, 2622 lesions were identified. In 59 (2.9%) of these patients, a total of 66 (2.5%) lesions were located in the periocular area. Thirty-two (48.5%) of these lesions were of the papular type, 15 (22.7%) the nodulo-ulcerative type, 10 (15.2%) the plaque type, and nine (13.6%) the nodular type. Dacryocystitis was identified in four patients with periocular involvement. Over the follow-up period, no ocular or periocular deformities or complications developed in these patients.

CONCLUSION

Patients suspected of CL should be evaluated and treated early in the course of their disease to prevent any permanent ocular or periocular deformities.

Histopathologically confirmed ocular rhinosporidiosis in two Canadians

CASE REPORT

In India and Southeast Asia, rhinosporidiosis is a common infectious disease, but it has rarely been reported in western countries. Infrequently, isolated ocular rhinosporidial infections have been reported, but to our knowledge, there are no reported cases in Canada. Two cases of rhinosporidiosis have been recently diagnosed and managed at our university-based hospital.

COMMENTS

Rhinosporidiosis presents with certain characteristic clinical features; however, the diagnosis is confirmed histopathologically. The presence of typical sporangia and spores in a fibrovascular stroma infiltrated by acute and chronic inflammatory cells including granulomas is diagnostic. Surgical excision is the treatment of choice, and recurrence is possible but rare.

Old World eyelid cutaneous leishmaniasis: a case report

Leishmania is a protozoa that may infect the skin, mucous, and viscera. The geographical distribution of cutaneous leishmaniasis (CL) is mainly determined by the sandfly vectors. The Old World type is mainly attributed to Leishmania major and Leishmania tropica, and in South of Europe only to Leishmania infantum. A 63-year-old woman, who noted a pimple on the external third of the left upper eyelid 6 months before. The lesion was nodular, well-defined and measured 1.1 cm in diameter and in height, simulating a basal cell carcinoma. It was surgically excised. CL diagnosis was made upon the histologic examination, which showed histiocytes with intracellular leishmania organisms. At 2 years followup, no evidence exists of cutaneous, mucous, or visceral involvement. Apart from carcinomas, nodular lesions with central ulceration are rare on the eyelid. A single cutaneous lesion of leishmania (oriental sore) has to be considered in the differential diagnosis, along with malignant eyelid neoplasms.

In vitro and in vivo killing of ocular Demodex by tea tree oil

AIMS

To compare the in vitro killing effect of different agents on Demodex and to report the in vivo killing effect of tea tree oil (TTO) on ocular Demodex.

METHODS

Survival time of Demodex was measured under the microscope. Sampling and counting of Demodex was performed by a modified method.

RESULTS

Demodex folliculorum survived for more than 150 minutes in 10% povidone-iodine, 75% alcohol, 50% baby shampoo, and 4% pilocarpine. However, the survival time was significantly shortened to within 15 minutes in 100% alcohol, 100% TTO, 100% caraway oil, or 100% dill weed oil. TTO's in vitro killing effect was dose dependent. Lid scrub with 50% TTO, but not with 50% baby shampoo, can further stimulate Demodex to move out to the skin. The Demodex count did not reach zero in any of the seven patients receiving daily lid scrub with baby shampoo for 40-350 days. In contrast, the Demodex count dropped to zero in seven of nine patients receiving TTO scrub in 4 weeks without recurrence.

CONCLUSIONS

Demodex is resistant to a wide range of antiseptic solutions. Weekly lid scrub with 50% TTO and daily lid scrub with tea tree shampoo is effective in eradicating ocular Demodex.

A case of palpebral dirofilariasis

PURPOSE

Dirofilaria repens infection is the most frequent and widespread dirofilariasis in the world. In Italy subcutaneous dirofilariasis is present especially in Northern-Central areas.

METHODS

A woman with a palpebral lump is presented.

RESULTS

After subcutaneous and muscular décollement, the authors found and removed a parasite. The final diagnosis was subcutaneous parasitosis due to D. repens.

CONCLUSIONS

Surgery was both diagnostic and therapeutic.

Ocular leishmaniasis: a case report

Cutaneous leishmaniasis (CL) is a protozoal disease which is endemic in Iran usually caused by Leishmaniasis major and Leishmaniasis tropica and transmitted by the bite of a sandfly. In Isfahan province CL is highly prevalent and we observe some unusual clinical features of disease. The eyelid is rarely involved possibly because the movement of the lids prevents the fly vector from biting the skin in this region. We report a case of ocular leishmaniasis with eyelid and conjunctival involvement that had simulated chalazion and was complicated with trichiasis. The patient was diagnosed by direct smear, culture, and PCR from the lesions. He was treated with systemic sodium stibogluconate (20 mg/kg/day) for 20 days and subsequently surgery for trichiasis. The patient was clinically cured with this treatment, however the disease had left complications, including palpebral and conjanctival scaring, corneal opacity, and eyelash loss.

Subcutaneous tumor of the lower eyelid: a potential manifestation of a Dirofilaria repens infection

PURPOSE

To report a case of Dirofilaria repens presenting as a subcutaneous tumor of the lower eyelid.

METHODS

Interventional case report.

RESULTS

A 29-year-old man of Greek origin without systemic symptoms presented with a 3-week history of a small painless mass localized in the medial part of the lower eyelid. There was no history of a preceding trauma, injury, or visual impairment; however, the patient had recently been on a holiday in Italy. The lesion persisted after systemic antibiotic treatment. Routine blood tests were normal and the efferent tear ducts were patent. Upon surgical intervention a yellowish, pea-sized cyst-like structure was found beneath the orbicularis muscle and removed in toto. Histologic examination revealed the presence of a wormlike structure with the characteristic features of a single adult Dirofilaria repens nematode.

CONCLUSIONS

Infection with the nematode Dirofilaria repens has to be considered in the differential diagnosis of malignant and benign tumors of subcutaneous periocular tissues in patients who traveled to endemic areas.

Eyelid sparganosis

PURPOSE

To report a case of sparganosis in the muscle layer of the eyelid.

DESIGN

Observational case report.

METHODS

A 67-year-old man with migratory painful swelling on the eyelid that was unresponsive to medications was evaluated and treated surgically.

RESULTS

Computed tomography showed a 1.5 x 1.5-cm sized, thick-walled lesion and ultrasound biomicroscopy showed hypoechoic tubular and cystic lesions. During surgery, a white, thread-like plerocercoid, 7 cm in length was detected in the orbicularis muscle of the lower eyelid. Histopathologic examination demonstrated the characteristic feature of the sparganum larva and foreign body granulomatous reaction. Serodiagnosis by enzyme-linked immunosorbent assay was positive. Three months postoperatively, the lesion resolved completely.

CONCLUSION

Although rare, sparganosis should be suspected in a moving eyelid mass unresponsive to the medical treatment.

[Symptomatic and asymptomatic infections of Demodex spp. in eye lashes of patients of different age groups]

Demodex folliculorum and Demodex brevis were looked for on eyelashes sampled from 481 people, aged 3 through 96. The persons studied were divided into 9 age groups. Magnitude of the infection symptoms was assessed based on macroscopic changes of eye-lid edges and on interviews with patients. An increase of the prevalence of infection and intensification of the symptoms were observed to coincide with the age increase of the persons studied. No significant differences were demonstrated between the infection frequencies of women and men. Symptoms of ocular demodecosis were more frequent only in women of group III (aged 21-30) and group V (41-50) (p < 0.05).

A four years old girl with phthiriasis pubis infestation

A four years old girl had Phthirus pubis infestation in the scalp, eyelids, eyelashes, neck and shoulders. She had fever, severe itching, allergic reaction and anxiety. The girl was successfully treated with 2.5% permethrin cream. The risk of lice infestation as a community health problem was discussed.

Orbital and adnexal cysticercosis

Orbital and adnexal cysticercosis is emerging as a far commoner disease than previously considered, both in endemic and nonendemic areas of cysticercosis. A review of the literature on orbital and adnexal cysticercosis found that it has a predilection for children and young adults with no definite sex predilection. The extraocular muscle form is the commonest type of orbital and adnexal cysticercosis. Lodgement of cysts in the subconjunctival space is another common site, followed by the eyelid, optic nerve, retro-orbital space and lacrimal gland. Association of orbital cysticercosis with systemic cysticercosis is quite rare. The clinical manifestations of orbital or adnexal cysticercosis are entirely different and depend on the location, size, relation to adjacent structures and stage of evolution of the cyst. Diagnosis of cysticercosis is based mainly on orbital imaging because of its highly specific appearance. Tissue diagnosis is not essential for initiating treatment. Medical therapy is the recommended treatment for the extraocular muscle form and retro-orbital cysticer-cosis. Surgical removal is advocated for subconjunctival and eyelid cysticercosis. Because of the limited number of cases of optic nerve and lacrimal gland cysticercosis, their treatment is controversial.

Orbital dirofilariasis

Dirofilariasis is a parasitic disease of domestic and wild animals that occasionally may present as zoonotic infection in humans. The microfilariae are accidentally transmitted to humans by Culex and Aedes mosquitoes. Ophthalmic infections with Dirofilaria are well documented all over the world, including America, Europe and Australia. The infection may be periorbital, subconjunctival or intraocular. In this report a case is described of orbital dirofilariasis that presented as ptosis and lid swelling. Australian ophthalmologists should consider dirofilariasis as part of the differential diagnosis of orbital swelling and inflammation.

Feline leishmaniosis due to Leishmania infantum in Italy

A case of leishmaniosis in domestic cats (Felis catus domesticus) is described. The subject showed a nodular lesion on the eyelid. The diagnosis was achieved by serological, parasitological, and light and electron microscopic investigations. By molecular techniques the aetiological agent was identified as belonging to Leishmania infantum, the species implicated in human and canine leishmaniosis in southern Europe. A preliminary study on the prevalence of asymptomatic feline leishmaniosis, performed in the areas where the infected cat was identified, revealed a low seroprevalence of infection: only 1 (0.9%) of the 110 cat sera examined by indirect fluorescent antibody test was positive for anti-Leishmania antibodies. Because clinical signs in feline leishmaniosis are unspecific and similar to those observed in other diseases commonly found in this species, leishmaniosis must be added to the differential diagnosis by feline veterinary practitioners and adequate serologic and histopathologic investigations must be performed in endemic areas.

[Cutaneous leishmaniasis of the lid]

We report 3 cases of patients presenting with lid cutaneous leishmaniasis in which clinical presentation was a true diagnostic problem. The patients were 3 women aged 46, 36, and 60 years. The first patient presented with an ulceration of the superior eyelid that had been treated as chalazion. The second patient had a chronic lesion of the eyelid, present for 1 year, fitting the criteria for tuberculosis, syphilis, or sarcoidosis. The last patient had an erosive lesion of the internal canthus, which was suspicious of basal cell carcinoma. The presence of other cutaneous lesions and the chronic progression led to a biopsy for anatomopathology and parasitology analysis. These analyses confirmed the diagnosis of cutaneous leishmaniasis. The patients were then treated with antimony derivatives. Progression of the disease was marked by the appearance of a pigmented nonretractile scar. The different clinical characteristics, epidemiology, and treatment of this affection are reviewed.

Ophthalmomyiasis in a child

A 4-year-old child presented with a 3-week history of left eye swelling. The periorbital inflammation was a result of a larva of the human botfly, Dermatobia hominis. Surgical extraction of the larva was curative.

An outbreak of trematode-induced granulomas of the conjunctiva

PURPOSE

To describe the epidemiologic, clinical, and histopathologic features of trematode granulomas of the conjunctiva, eyelid, and anterior chamber in pediatric patients.

DESIGN

Prospective noncomparative case series.

PARTICIPANTS

Forty-one children from a southern Indian village with conjunctival granulomas.

METHODS

The village of Sellananthal was selected for a field visit after analysis of earlier hospital-based allergic conjunctival granuloma cases. Children with ocular diseases were examined, and histories of exposure to assumed risk factors and clinical findings were evaluated. Selected patients were brought to the base hospital for excisional biopsy. Serial sections obtained from the excised nodules were examined for the presence of a parasite.

MAIN OUTCOME MEASURES

Histopathologic examination of excised conjunctival lesions or response of lesions to local medical therapy.

RESULTS

In this year-long prospective study, 41 children (16 years or younger; 38 boys and 3 girls) with clinical features of allergic conjunctival granulomas were examined. Thirty-four patients were from a single village located in the southern Indian state of Tamil Nadu; the remaining 7 were from various parts of the same state. All children swam in their village's freshwater pond. Twenty patients with nodules less than 5 mm in diameter received medical treatment; 13 with larger nodules underwent surgical excision of the lesions. Nine of these 13 cases revealed a zonal granulomatous inflammation admixed with eosinophilic leukocytes; 4 of these 9 displayed fragments of the tegument and internal structures of a trematode and Splendore-Hoeppli phenomenon. The remaining 4 of the 13 cases revealed nongranulomatous inflammation made up of lymphocytes, histiocytes, and eosinophils. Eight patients refused surgical treatment.

CONCLUSIONS

In southern India, one cause of allergic conjunctival granulomas in children seems to be trematode infection. The clustering of cases in a single village and exposure to a village freshwater pond indicate the need for an epidemiologic investigation and study of the parasite's life cycle. Sporadic cases from other parts of the state with similar histories of exposure to their local pond or river water suggest a widespread distribution of the etiologic agent.