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Fig. 1 (English and associates). Scanning electron microscopic view of eyelid margin displaying the protruding tail of a demodectic mite beside an eyelash (X 550).
scanning electron microscopy.' We were interested to see if these parasites could also be isolated on the eyelid margin. After a full-thickness resection for a shortening procedure of the lower eyelid of a 35-yearold woman, we took the specimen and placed it in 4% glutaraldehyde solution. This was then placed in 100% amylacetate and critically point dried. The sample was oriented on an aluminum stub, gold coated in a polaron sputter coater with 20 nm of gold, and viewed with a scanning electron microscope. After orientation of the eyelid under low power with the electron microscope, the tissue fragment was rotated to allow the eyelid margin to be examined in profile. Eyelashes were examined under higher magnifications, and acarid infestation of the cilium was recorded (Fig. 1). The tail of the parasite Demodex folliculorum was observed as a dome-shaped object contiguous with an eyelash and protruding from the eyelid margin. It displayed the characteristic annular bands found on the abdomen. The peculiar pattern of these striations was observed under higher magnification (Fig. 2). Only the terminal portion of the abdomen of the parasite was identified. Demodex brevis, the other species of the mite found in the eyelid, occurring in the meibomian glands and pilosebaceous complex, has a pointed caudate extremity and was not observed in our patient. The degree of infestation was not as
Fig. 2 (English and associates). Higher magnification of parasite showing classic inscriptions on the abdomen (x 2,320).
heavy as that recorded in the facial skin studies in which multiple parasites were noted around hairs.
Reference 1. Crosti, c., Menni, 5., Sala, F., and Piccinno, R.: Demodectic infestation of the pilosebaceous follicle. J. Cutan. Pathol. 10:257, 1983.
Capnocytophaga canimorsus as the Cause of a Chronic Corneal Infection Marc D. de Smet, M.D., Chi Chao Chan, M.D., Robert B. Nussenblatt, M.D., and Alan G. Palestine, M.D. Laboratory of Immunology, National Eye Institute. Inquiries to Marc D. de Smet, M.D., Laboratory of Immunology, National Eye Institute, Bldg. 10, Rm. 10N202, Bethesda, MD 20892.
Dysgonic fermenter 2, a normal inhabitant of the dog's mouth, closely resembles the Capnocytophaga species found in humans. The latter have been shown to cause a chronic keratitis resembling a fungal or Acanthamoeba infec-
Vol. 109, No.2
Letters to the Journal
241
tion. I ,2 Dysgonic fermenter 2 is recognized as a cause of fulminant septicemia in patients without spleens or with alcoholic cirrhosis." Infection frequently occurs after a dog bite or close contact with dogs or cats. The organism, a gliding gram-negative rod, is characterized by fastidious growth requirements. We treated a patient who developed a chronic deep corneal infection that required prolonged antibiotic therapy over several months because of this organism. A 46-year-old veterinarian was struck on the right eye by a carious tooth while extracting it from a poodle with severe gingivitis. The patient sustained a superficial corneal laceration extending into the anterior stroma without any retained foreign body. He was treated with topical sulfacetamide. While taking this regimen, the patient developed an intense photophobia and conjunctival injection. The site of injury was debrided and showed a staphylococcal species which was treated with topical fortified cefazolin (50 mg/ ml) for two weeks. Visual acuity improved to R.E.: 20/25 with partial resolution of the photophobia. Visual acuity again deteriorated and the photophobia worsened within a month. A microscopic abscess growing C. perfringens was noted and debrided. The cornea was treated with topical fortified vancomycin hydrochloride. Visual acuity improved to R.E.: 20/25, only to worsen within one month to R.E.: 20/200 despite treatment. Two months later and three days before admission to the National Eye Institute, visual
acuity had decreased to counting fingers. The patient had an anterior chamber hypopyon. An aspirate of the anterior chamber did not show any organisms, but it did contain numerous polymorphonuclear cells. Slit-lamp examination disclosed marked conjunctival injection and an edematous cornea with an intact epithelium. Plaquelike deposits were seen at the level of the endothelium (Fig. 1). These deposits had well defined borders extending inward from the peripheral cornea. Smaller satellite lesions were also noted. A biopsy specimen taken from one of the lesions did not show any organisms but, once again, was characterized by a profusion of polymorphonuclear leukocytes. After five days, the anaerobic cultures disclosed a thin, nonspore-forming gram-negative rod measuring 1 to 311m. This was characterized as a dysgonic fermenter 2 organism (Fig. 2). The patient was treated with a combination of intravenous cefazolin, 1 g every six hours, and topical eye drops of cefazolin sodium, 50 mg Zml every hour. The patient was later switched to penicillin, 2,000,000 units intravenously every six hours and 100,000 U/ml topically, after he developed an allergic reaction to cefazolin. The eyedrops were continued for several months. Visual acuity improved to R.E.: 20/30 with a gradual lessening of the photophobia. The eye drops were finally discontinued after the endothelial deposits and the photophobia had resolved. Dysgonic fermenter 2 behaves in a way similar to other Capnocytophaga species. It is characterized by severe pain, decreased visual acuity,
Fig. 1 (de Smet and associates). Slit-lamp appearance of the corneal subendothelial infiltrate one day postoperatively. Note the satellite lesions and the sharp demarcation of each lesion.
Fig. 2 (de Smet and associates). Appearance of the organism on Gram stain after seven days in culture (x 100). The organism is a gram-negative rod measuring 1 to 3 urn.
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and slow, fastidious growth in culture. Anaerobic cultures must be maintained beyond the usual five days to detect this organism. This growth also occurs in vivo, which explains why the patient suffered three recurrences, each time with a deeper involvement. The bacterium, because of its slow growth, requires prolonged therapy for its eradication. Photophobia, possibly related to bacterial spread along corneal nerves, is probably the best indicator of persistent infection. Dysgonic fermenter 2 has a wide spectrum of antibiotic sensitivity. It is particularly sensitive to penicillin, clindamycin, and rifampin.! Dysgonic fermenter 2 corneal involvement can mimic fungal, acanthamebal, or stromal keratitis. One should suspect this organism in cases where a dog's oral flora may have infected the cornea.
References 1. Parnel. G. J., Buckley, D. J., Frucht, J., Krausz, H., and Feldman, S. T.: Capnocytophaga keratitis. Am. J. Ophthalmol. 107:193, 1989. 2. Heidemann, D. G., Pflugfelder, S. c.. Kronish, J., Alfonso, E. c.. Dunn, S. P., and Ullman, S.: Necrotizing keratitis caused by Capnocytophaga ochracea. Am. J. Ophthalmol. 105:655, 1988. 3. Brenner, D. J., Hollis, D. G., Fanning, G. R., and Weaver, R. E.: Capnocqtophaga canimorsus sp. nov. (formerly CDC group DF-2), a cause of septicemia following dog bite, and C. cynodegmi sp. nov., a cause of localized wound infection following dog bite. J. Clin. Microbiol. 27:231, 1989. 4. Verghese, A., Hamati, F., Berk, S., Franzus, B., Berk, 5., and Smith, J. K.: Susceptibility of dysgonic fermenter 2 to antimicrobial agents in vitro. Antirnicrob. Agents Chemother. 32:78, 1988.
February, 1990
Inquiries to Careen Y. Lowder, M.D., Department of Ophthalmology, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195-5024.
Microsporidia are obligate intracellular parasites that infect mammals, arthropods, fish, and birds. They rarely cause disease in humans.' Recently, however, microsporidia have been associated with hepatitis and enteritis in patients with the acquired immunodeficiency syndrome (AIDS).2 We encountered a case of microsporidia corneal infection in an individual who was seropositive for human immunodeficiency virus antibodies. A 30-year-old homosexual man with AIDSrelated complex and known to be HIVseropositive for three years, began having recurrent episodes of redness and crusting of both eyes in November 1988. Conjunctival cultures grew Streptococcus viridans and coagulase-negative staphylococcus. The patient was treated with the appropriate topical antibiotics without resolution of the condition. Ocular examination in February 1989 disclosed a bestcorrected visual acuity of 20/25 in each eye. Slit-lamp examination showed marked bilateral conjunctival hyperemia, mixed follicular-papillary tarsal conjunctival reaction, and diffuse punctate epithelial keratopathy. Conjunctival cultures for bacteria, fungi, chlamydia, herpes simplex virus, herpes zoster virus, and adenovirus were negative. The patient's epithelial keratopathy worsened over the next three months, and visual acuity deteriorated to 20/60 in each eye (Fig. 1). In May 1989 corneal epithelium was scraped from the right eye and healed rapidly, but the epithelial keratopathy recurred. Epithelial scrapings were submitted for cul-
Microsporidia Infection of the Cornea in a Man Seropositive for Human Immunodeficiency Virus Careen Y. Lowder, M.D., David M. Meisler, M.D., James T. McMahon, Ph.D., David L. Longworth, M.D., and Isobel Rutherford, M.D. Departments of Ophthalmology (C.Y.L., D.M.M.), Pathology (J.T.M.), Infectious Disease (D.L.L.), and Microbiology (l.R.), Cleveland Clinic Foundation.
Fig. 1 (Lowder and associates). Slit-lamp photograph of punctate epithelial keratopathy.
February, 1990
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (English and associates). Scanning electron microscopic view of eyelid margin displaying the protruding tail of a demodectic mite beside an eyelash (X 550).
scanning electron microscopy.' We were interested to see if these parasites could also be isolated on the eyelid margin. After a full-thickness resection for a shortening procedure of the lower eyelid of a 35-yearold woman, we took the specimen and placed it in 4% glutaraldehyde solution. This was then placed in 100% amylacetate and critically point dried. The sample was oriented on an aluminum stub, gold coated in a polaron sputter coater with 20 nm of gold, and viewed with a scanning electron microscope. After orientation of the eyelid under low power with the electron microscope, the tissue fragment was rotated to allow the eyelid margin to be examined in profile. Eyelashes were examined under higher magnifications, and acarid infestation of the cilium was recorded (Fig. 1). The tail of the parasite Demodex folliculorum was observed as a dome-shaped object contiguous with an eyelash and protruding from the eyelid margin. It displayed the characteristic annular bands found on the abdomen. The peculiar pattern of these striations was observed under higher magnification (Fig. 2). Only the terminal portion of the abdomen of the parasite was identified. Demodex brevis, the other species of the mite found in the eyelid, occurring in the meibomian glands and pilosebaceous complex, has a pointed caudate extremity and was not observed in our patient. The degree of infestation was not as
Fig. 2 (English and associates). Higher magnification of parasite showing classic inscriptions on the abdomen (x 2,320).
heavy as that recorded in the facial skin studies in which multiple parasites were noted around hairs.
Reference 1. Crosti, c., Menni, 5., Sala, F., and Piccinno, R.: Demodectic infestation of the pilosebaceous follicle. J. Cutan. Pathol. 10:257, 1983.
Capnocytophaga canimorsus as the Cause of a Chronic Corneal Infection Marc D. de Smet, M.D., Chi Chao Chan, M.D., Robert B. Nussenblatt, M.D., and Alan G. Palestine, M.D. Laboratory of Immunology, National Eye Institute. Inquiries to Marc D. de Smet, M.D., Laboratory of Immunology, National Eye Institute, Bldg. 10, Rm. 10N202, Bethesda, MD 20892.
Dysgonic fermenter 2, a normal inhabitant of the dog's mouth, closely resembles the Capnocytophaga species found in humans. The latter have been shown to cause a chronic keratitis resembling a fungal or Acanthamoeba infec-
Vol. 109, No.2
Letters to the Journal
241
tion. I ,2 Dysgonic fermenter 2 is recognized as a cause of fulminant septicemia in patients without spleens or with alcoholic cirrhosis." Infection frequently occurs after a dog bite or close contact with dogs or cats. The organism, a gliding gram-negative rod, is characterized by fastidious growth requirements. We treated a patient who developed a chronic deep corneal infection that required prolonged antibiotic therapy over several months because of this organism. A 46-year-old veterinarian was struck on the right eye by a carious tooth while extracting it from a poodle with severe gingivitis. The patient sustained a superficial corneal laceration extending into the anterior stroma without any retained foreign body. He was treated with topical sulfacetamide. While taking this regimen, the patient developed an intense photophobia and conjunctival injection. The site of injury was debrided and showed a staphylococcal species which was treated with topical fortified cefazolin (50 mg/ ml) for two weeks. Visual acuity improved to R.E.: 20/25 with partial resolution of the photophobia. Visual acuity again deteriorated and the photophobia worsened within a month. A microscopic abscess growing C. perfringens was noted and debrided. The cornea was treated with topical fortified vancomycin hydrochloride. Visual acuity improved to R.E.: 20/25, only to worsen within one month to R.E.: 20/200 despite treatment. Two months later and three days before admission to the National Eye Institute, visual
acuity had decreased to counting fingers. The patient had an anterior chamber hypopyon. An aspirate of the anterior chamber did not show any organisms, but it did contain numerous polymorphonuclear cells. Slit-lamp examination disclosed marked conjunctival injection and an edematous cornea with an intact epithelium. Plaquelike deposits were seen at the level of the endothelium (Fig. 1). These deposits had well defined borders extending inward from the peripheral cornea. Smaller satellite lesions were also noted. A biopsy specimen taken from one of the lesions did not show any organisms but, once again, was characterized by a profusion of polymorphonuclear leukocytes. After five days, the anaerobic cultures disclosed a thin, nonspore-forming gram-negative rod measuring 1 to 311m. This was characterized as a dysgonic fermenter 2 organism (Fig. 2). The patient was treated with a combination of intravenous cefazolin, 1 g every six hours, and topical eye drops of cefazolin sodium, 50 mg Zml every hour. The patient was later switched to penicillin, 2,000,000 units intravenously every six hours and 100,000 U/ml topically, after he developed an allergic reaction to cefazolin. The eyedrops were continued for several months. Visual acuity improved to R.E.: 20/30 with a gradual lessening of the photophobia. The eye drops were finally discontinued after the endothelial deposits and the photophobia had resolved. Dysgonic fermenter 2 behaves in a way similar to other Capnocytophaga species. It is characterized by severe pain, decreased visual acuity,
Fig. 1 (de Smet and associates). Slit-lamp appearance of the corneal subendothelial infiltrate one day postoperatively. Note the satellite lesions and the sharp demarcation of each lesion.
Fig. 2 (de Smet and associates). Appearance of the organism on Gram stain after seven days in culture (x 100). The organism is a gram-negative rod measuring 1 to 3 urn.
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AMERICAN JOURNAL OF OPHTHALMOLOGY
and slow, fastidious growth in culture. Anaerobic cultures must be maintained beyond the usual five days to detect this organism. This growth also occurs in vivo, which explains why the patient suffered three recurrences, each time with a deeper involvement. The bacterium, because of its slow growth, requires prolonged therapy for its eradication. Photophobia, possibly related to bacterial spread along corneal nerves, is probably the best indicator of persistent infection. Dysgonic fermenter 2 has a wide spectrum of antibiotic sensitivity. It is particularly sensitive to penicillin, clindamycin, and rifampin.! Dysgonic fermenter 2 corneal involvement can mimic fungal, acanthamebal, or stromal keratitis. One should suspect this organism in cases where a dog's oral flora may have infected the cornea.
References 1. Parnel. G. J., Buckley, D. J., Frucht, J., Krausz, H., and Feldman, S. T.: Capnocytophaga keratitis. Am. J. Ophthalmol. 107:193, 1989. 2. Heidemann, D. G., Pflugfelder, S. c.. Kronish, J., Alfonso, E. c.. Dunn, S. P., and Ullman, S.: Necrotizing keratitis caused by Capnocytophaga ochracea. Am. J. Ophthalmol. 105:655, 1988. 3. Brenner, D. J., Hollis, D. G., Fanning, G. R., and Weaver, R. E.: Capnocqtophaga canimorsus sp. nov. (formerly CDC group DF-2), a cause of septicemia following dog bite, and C. cynodegmi sp. nov., a cause of localized wound infection following dog bite. J. Clin. Microbiol. 27:231, 1989. 4. Verghese, A., Hamati, F., Berk, S., Franzus, B., Berk, 5., and Smith, J. K.: Susceptibility of dysgonic fermenter 2 to antimicrobial agents in vitro. Antirnicrob. Agents Chemother. 32:78, 1988.
February, 1990
Inquiries to Careen Y. Lowder, M.D., Department of Ophthalmology, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195-5024.
Microsporidia are obligate intracellular parasites that infect mammals, arthropods, fish, and birds. They rarely cause disease in humans.' Recently, however, microsporidia have been associated with hepatitis and enteritis in patients with the acquired immunodeficiency syndrome (AIDS).2 We encountered a case of microsporidia corneal infection in an individual who was seropositive for human immunodeficiency virus antibodies. A 30-year-old homosexual man with AIDSrelated complex and known to be HIVseropositive for three years, began having recurrent episodes of redness and crusting of both eyes in November 1988. Conjunctival cultures grew Streptococcus viridans and coagulase-negative staphylococcus. The patient was treated with the appropriate topical antibiotics without resolution of the condition. Ocular examination in February 1989 disclosed a bestcorrected visual acuity of 20/25 in each eye. Slit-lamp examination showed marked bilateral conjunctival hyperemia, mixed follicular-papillary tarsal conjunctival reaction, and diffuse punctate epithelial keratopathy. Conjunctival cultures for bacteria, fungi, chlamydia, herpes simplex virus, herpes zoster virus, and adenovirus were negative. The patient's epithelial keratopathy worsened over the next three months, and visual acuity deteriorated to 20/60 in each eye (Fig. 1). In May 1989 corneal epithelium was scraped from the right eye and healed rapidly, but the epithelial keratopathy recurred. Epithelial scrapings were submitted for cul-
Microsporidia Infection of the Cornea in a Man Seropositive for Human Immunodeficiency Virus Careen Y. Lowder, M.D., David M. Meisler, M.D., James T. McMahon, Ph.D., David L. Longworth, M.D., and Isobel Rutherford, M.D. Departments of Ophthalmology (C.Y.L., D.M.M.), Pathology (J.T.M.), Infectious Disease (D.L.L.), and Microbiology (l.R.), Cleveland Clinic Foundation.
Fig. 1 (Lowder and associates). Slit-lamp photograph of punctate epithelial keratopathy.
