Microsporidiosis

1. MICROSPORIDIOSIS Sujay Chauhan

2. • 29 years • Male • Pondicherry • Manager, pharmaceutical company CASEI

3. • Redness • Watering • Blurring of vision • Photophobia CHIEF COMPLAINTS Left eye x 10 days

4. HISTORY OF PRESENT ILLNESS Patient was apparently alright 10 days ago when he noticed redness, watering, blurring of vision and photophobia in left eye on waking up in the morning No complaint of ocular discharge, cough, cold or skin vesicles Consulted Vasan eye care where eye drops moxifloxacin and carboxymethylcellulose were prescribed - no relief

5. No history of: • Ocular trauma or foreign body • Contact lens wear • Long term use of any eye drop or other medication • Diabetes mellitus • Any other chronic systemic illness

6. No history of similar episodes in past PAST HISTORY

7. GENERAL PHYSICAL EXAMINATION • Average built and height • Conscious, cooperative and well oriented

8. OCULAR EXAMINATION OD OS BCVA 6/5, N6 6/12, N10 NCT 9 mm Hg 10 mm Hg Lids Normal Edematous ROPLAS Negative Negative Conjunctiva Normal Congested No papillae or follicles No foreign body Sclera Normal Normal

9. Cornea Clear • Multiple superficial punctate grey-white epithelial infiltrates <1mm with distinct margins over central cornea (fluorescein stain+) • Few subepithelial infiltrates • No keratic precipitates • Sensation normal

10. 10X

11. 10X

12. 25X

13. Anterior chamber Normal depth & quiet Normal depth & quiet Iris Normal Normal Pupil Round, normal reaction to light Round, normal reaction to light Lens Clear Clear Fundus Cup:Disc ratio = 0.3:1 Healthy neuroretinal rim Macula & blood vessels normal Cup:Disc ratio = 0.2:1 Healthy neuroretinal rim Macula & blood vessels normal

15. DIFFERENTIAL DIAGNOSIS • Adenoviral keratitis • Herpes simplex/zoster superficial punctate keratitis • Microsporidial keratoconjunctivitis • Mycobacterial keratitis • Thygeson superficial punctate keratitis

16. INVESTIGATIONS

17. Gram stain Corneal scraping

18. • Few healthy and degenerated epithelial cells • Few pus cells • Fibrinous exudates • No bacterial agent could be made out Narayana Nethralaya Laboratories, Reference number: N33711

19. Potassium hydroxide (KOH) + Calcofluor white stain

21. Many round to oval fluorescent bodies resembling microsporidia (stars in sky appearance) Narayana Nethralaya Laboratories, Reference number: N33711

22. DIAGNOSIS Left eye microsporidial superficial punctate keratoconjunctivitis

23. Anterior Segment Optical Coherence Tomography (AS-OCT)

26. • Tablet Albendazole 400 mg OD x 7 days Left eye • Eye ointment Neosporin® (Neomycin, Bacitracin & Polymyxin B) QID x 20 days • Eye drop Flurometholone 0.1% QID x 5 days TDS x 5 days BD x 5 days OD x 5 days TREATMENT

27. FOLLOW UP AT 1 WEEK • Symptomatic improvement • Decreased conjunctival congestion • Reduced corneal epithelial and subepithelial infiltrates

28. 10X

29. • 20 years • Female • Anekal, Bangalore • Student CASEII

30. • Redness • Watering • Foreign body sensation CHIEF COMPLAINTS Right eye x 5 days

31. No history of: • Ocular trauma or foreign body • Long term use of any eye drop • Contact lens wear • Diabetes mellitus • Any chronic illness Consulted a private practitioner - prescribed eye drop Ciprofloxacin + Dexamethasone - no improvement

32. 16X

33. 25X

34. • 44 years • Male • Gopalganj, Bihar • Farmer CASEIII

35. • Redness • Watering • Burning sensation • Blurring of vision • Lower lid swelling CHIEF COMPLAINTS Left eye x 15 days

36. Used some eye drops prescribed by a private practitioner - no relief

37. 16X

38. 25X

39. FUNGI DISCUSSION PROTOZOA Rx!!! ???

40. • Protozoa. Recent studies: related to kingdom fungi • 3.5-5 µ x 2-3 µ • True nucleus, prokaryotic-like ribosome, lacks mitochondria • Spore forming • Obligate intracellular parasite – vertebrates and invertebrates • First recognised - 1857 • First reported - 1973, vascularised corneal scar Alkatan HM, Al-Zaaidi S, Athmanathan S. Microsporidial keratitis. Saudi J Ophthalmol. 2012 Apr; 26(2): 199–203

41. • Gastrointestinal tract • Eye • Lung • Kidney • Sinus • Immunocompromised • Increased prevalence of HIV infection - more case reports of microsporidiosis

42. 1200 species identified. 12 cause human infection. Family Genera Species Microsporidia Microsporidium M. ceylonensis M. africanum Encephalitozoonidea Encephalitozoon E. cuniculi E. intestinalis Nosematidea Nosema N. ocularum N. connori Brachlola B. algerae B. vescularum Enterocytozoonidae Enterocytozoon E. bleneusi Pleistophoridea Trachipleistophora T. hominis T. anthopophthera anthopophtheraSource: Chaudhari Z, Vananthi M. Postgraduate ophthalmology. 2012; 539.

43. Recent outbreak in different parts of world: • Increased awareness • High level of suspicion • Precise knowledge of disease • Better diagnostic methods Microsporidiosis outbreak

44. PREDISPOSING FACTORS

45. • Trauma • Contaminated water or soil • Topical or systemic corticosteroid use • Contact lens • Immunosuppression • Contact with infected person, domestic animals (cats, birds)

46. LIFE CYCLE • Transmission of spores through air and water • Direct inoculation, ingestion or inhalation

47. Spores Sporoplasms Merogony Merogony Spore with tubule Host cell Sporoblasts

48. I. Superficial punctate keratoconjunctivitis – Encephalitozoon – Immunocompromised CLINICAL PRESENTATIONS

49. II. Deep corneal stromal keratitis – Nosema & Microsporidium – Immunocompetent – Chronic refractive infection – Mimics herpetic keratitis – Uveitis – Corneal neovascularisation – Necrosis – Perforation – Poor prognosis

50. Source: Vemuganti et al. BMC Ophthalmology 2005,5(1):19

51. Source: Vemuganti et al. BMC Ophthalmology 2005,5(1):19

52. CLINICAL SUSPICION • Atypical multifocal epithelial keratitis • Non-resolving keratitis with conventional anti-microbial treatment • Chronic culture-negative stromal keratitis ?

53. CONFIRMATION • Isolating the spores • Difficult due to inadequate samples obtained from corneal scrapings • Occasionally conjunctival scraping

54. Gram’s stain Mild Gram positive Source: Vemuganti et al. BMC Ophthalmology 2005,5(1):19

55. Giemsa stain Epithelial cells containing cytoplasmic inclusion bodies Source: Illinois Natural History Survey, 2015

56. 1% acid-fast stain Bright red with darkly stained band at the tip Source: Vemuganti et al. BMC Ophthalmology 2005,5(1):19

57. Modified trichrome stain Intracellular pink or red spherical bodies Source: www.studyblue.com

58. • Immunofluorescence • Electron microscopy • PCR • Confocal microscopy

59. TREATMENT TOPICAL • Fumagillin 70ug/ml (Aspergillus fumigatus, most specific) • Hexamidine 0.1% • Propamidine 0.1% • Fluoroquinolones (moxifloxacin 0.5%, levofloxacin 0.5%, ciprofloxacin 0.3%) • Neomycin, Polymyxin B, Bacitracin • Chlorhexidine 0.02%

60. ORAL • Albendazole 400 mg BD • Itraconazole 400 mg OD • Benzimidazole 100-5000 mg/day

61. • HAART for AIDS • Epithelium debridement (increased risk of stromal infiltration & secondary infection) • Penetrating keratoplasty, deep anterior lamellar keratoplasty (DALK)

Microsporidiosis

Microsporidiosis

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