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Microsporidia keratoconjunctivitis: disease that should not be missed!
Session Title: Inflammation
Session Date/Time: Tuesday 08/10/2013 | 16:30-18:00
Paper Time: 17:28
Venue: Auditorium (First Floor)
First Author: : U.Reinprayoon THAILAND
Co Author(s): : N. Kasetsuwan P. Chantaren
To demonstrate clinical characteristics of microsporidia keratoconjunctivitis in healthy individuals
Cornea and refractive surgery unit, Department of Ophthalmology, King Chulalongkorn memorial hospital, Bangkok, Thailand
Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University
Department of Parasitology, Faculty of Medicine, Chulalongkorn University
A retrospective non-comparative case series. The medical records, slit lamp photographs, confocal microscopic findings of the patients diagnosed with microsporidia keratoconjunctivitis were reviewed. The definite diagnosis was made by the positive cornea epithelial scrapings stained with modified trichrome.
Twenty eight patients were included. There were predominantly male (57%). The mean age was 36 years (range 8 76). Unilateral involvement was found in 19 patients (86%). The most identified risk factors were sports with soil or mud contamination (32%), dirty water (14%) and raindrops (7%). One patient was contact lens wearer. The mean onset of keratoconjunctivitis was 9 days. Coarse punctate epithelial keratitis (PEK) was found in 100% of cases. The PEK was typically white, flaky, varying in size. Bizarre shapes of PEK could be described as a donut, target, pseudodendrites, cornflake or dumbbell. 54% and 29% of cases developed nummular subepithelial infiltrates and anterior uveitis at 1-3 weeks respectively. Limbitis was found in 14% especially in children. Conjunctival follicular reaction was common. Lymph node enlargement and marked eyelid swelling was also found. The confocal microscope demonstrated small oval hyper-refractile particles of 3.5-5 x 2-3 microns, which gave 60% sensitivity in our series (9 out of 15 cases). All patients responded well to topical fluoroquinolone, topical fumagillin, systemic albendazole and/or epithelial debridement. Topical steroid was applied in 36% of cases to treat the subsequent nummular keratitis or uveitis. One case had recurrence at 8 weeks after 1st treatment.
Microsporidial keratoconjunctivitis can mimic an acute viral keratoconjunctivitis. We proposed three clinical clues for diagnosis. First clue was the discrete multiple white flakes on corneal epithelium presenting in bizarre shape and vary in size which were typical. The second was the coincided follicular conjunctival reaction. Exposure to water, soil or mud was the last clue for the diagnosis, especially in a group of patients exposed to the same risk factor at the same period of time (e.g. a team of football players). Treatment with corneal epithelial debridement adjuncted with topical fluoroquinolone, fumagillin and / or oral albendazole showed impressive outcome. Topical corticosteroid was indicated in patients with subsequent nummular subepithelial infiltrates and anterior uveitis. However, anterior chamber inflammation was uncommon. If it occurred, inflammation was not severe. Confocal microscope is a non-invasive instrument to facilitate the diagnosis of microsporidial keratoconjunctivitis, although it required experience of the clinicians to interpret the results.