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Parinaud oculoglandular syndrome: a report of two cases

Poster Details

First Author: L.Murad BRAZIL

Co Author(s):    F. Abreu   R. Correia   R. Bueno De Moraes        

Abstract Details



Purpose:

To relate the clinical presentation and the evolution of two cases of Parinaud oculoglandular syndrome at the Cornea Service of Policlínica Naval (PNN) in the town of Niterói, State of Rio de Janeiro, Brazil

Setting:

The Parinaud oculoglandular syndrome consists of a granulomatous conjunctivitis associated to a regional lymphadenopathy which has as its most frequent reason the cat scratch disease. Currently there are several etiologic causes described for the syndrome, such as tularemia, lynphogranuloma venereum, sporotrichosis, and rickettsiosis; however, the specific etiological agent of the cat scratch disease is Bartonella henselae. In 2002 a case was reported of Parinaud octoglandular syndrome associated with infection by Paracoccidioides brasiliensis . The cat scratch disease was initially described by Parinaud in 1889. Several ocular and systemic formats of presenting such pathology have been evidenced, among which are conjunctivitis, anterior, intermediate and posterior uveitis, vasculitis, retina infiltrates, neuroretinitis, neurologic and hematologic affections.

Methods:

This is the story of two patients treated at the Cornea Service of PNN. All medical visits were documented and the images recorded with the patients’ consent. At each visit, a complete ophthalmologic examination was carried out, including visual acuity, biomicroscopy, applanation tonometry and ophthalmoscopy

Results:

CCB, 21 years old, male, reported “a prolonged conjunctivitis”. The symptoms started 3 weeks before, with conjunctival hyperemia in the left eye and ocular itching. One week after the onset, the patient sought ophthalmologic emergency service, where topical antihistaminic were prescribed. At that time,the biomicroscopy evidenced eyelid edema on the left,diffuse bulbar conjunctival hyperemia, follicles, granuloma in the inferior tarsal conjunctiva and a tactile preauricular lymph node. NSF, 11 years old, female,reported a “strong conjunctivitis” in the right eye the onset of the disease one month before, with symptoms of ocular itching and hyperemia, when she was examined by a pediatrician who started topical tobramycin .The biomicroscopy evidenced granulous lesions in the inferior and superior tarsal conjunctiva, follicles, hyperemia of the bulbar conjunctiva and an ipsilateral preauricular tactile lymph node. Both patients presented visual acuity 1.0 for both eyes ,a good overall disposition, but reported random episodes of fever since the beginning of the symptoms. Neither of the patients reported cat scratch but both reported having a cat at home. Exams for sporotrichosis, tuberculosis, sarcoidosis and bartonellosis, radiologic exam of the thorax and PPD were request. The serology was positive for Bartonella henselae. Oral doxycycline was prescribed for 10 days

Conclusions:

In both cases the patients were evaluated previously and the initial approach was aimed at treating an allergic conjunctivitis in the first patient and an infectious bacterial conjunctivitis in the second patient. The toxicity caused by the continuous usage of the medication may have helped make the evaluation of symptoms and signs more difficult. The epidemiologic history, the detailed medical history and the failure of the initial treatment were fundamental for the conduction of an etiologic investigation. The Parinaud oculoglandular syndrome presents itself most of the times with a number of symptoms that are very usual in the ophthalmologic practice, which allows for this hypothesis to be investigated very infrequently in the absence of a detailed epidemiologic and social history, and it is often confused with entities of inflammatory, infectious or allergic etiology. Serology in Brazil is very costly, which makes its performance only used for scientific purposes. Other methods auxiliary for diagnosis such as aspiration puncture of the pre-auricular lymph node and excisional biopsy of the conjunctival lesions are invasive procedures and their real benefit should be carefully considered. A conjunctival swab was performed and the cell exam reported a sample with little hemorrhagic basis with a dispersion of small and atypical lymphocytes and the cultures were negative. A fine needle aspiration on lymph node was performed and the cell exam report evidenced a cytopathic disease compatible with the lymphoid structure puncture with a predominance of regular chromatin lymphocytes and rare, loose nucleoli. Some points must be observed in these cases: Patients with a clinically defined diagnosis, but without therapeutic success, must be thoroughly evaluated for the purpose of ruling out other less usual diagnoses. Finally, in cases where this syndrome is among the diagnostic options, the joint approach with other specialists is fundamental as well as laboratory support

Financial Disclosure:

NONE

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