TRANSACTIONSOF THE ROYAL SOCIETY OFTROPICAL MEDICINEANDHYGIENE(1992) 86,317-320

Causes of conjunctivitis

and keratoconjunctivitis

317

in Karachi, Pakistan

R. M. Woodlandl*, S. Darougar’, U. Thaker’, L. Cornell’, M. Siddique’, J. Warda and M. Shah2 ‘Department of Public Health Ophthalmology, Institute of Ophthalmology, Judd Street, London, WCIH 9QS, UK; 2The Layton-Rahmatulla Benevolent Trust, Karachi, Pakistan Abstract

The causesof conjunctivitis and keratoconjunctivitis in 388 patients who attended eye casualty departments in Karachi, Pakistan, during a 5 month period were investigated. Most of these infections were diagnosed as adenovirus (291, 75%) or bacterial (71, 18.3%). Of the remainder, 9 cases(2.3%) were caused by herpes simplex virus and 7 (1.SO/,)by Chalmydia trachomatis. There was no evidence of typical active trachoma in this urban population. Bacteria or Candida albicans were also grown from 44 of the adenovirus cases(15%). Many of the bacteria grown from eyesin this study were resistant to antibiotics, probably becauseof inadequate andior inappropriate self-medication with antibiotics in this community. Introduction

Ocular infections are responsible for the majority of casesof preventable and/or curable ocular morbidity and blindness. They account for a large proportion of all ocular morbidity seen by family doctors, general practitioners, health centres, and ophthalmologists in both developed and developing countries (DAROUGAR et al., 1989; DART, 1986; JONES et al., 1986). Previous reports have shown that the major causesof ocular infections in developed countries are adenovirus, herpes simplex virus (HSV) and chlamydiae (DAROUGAR et al., 1987; WISHART et al., 1984). However, little is known about the importance of these agents as causesof ocular infections in developing countries. In this paper we report the relative prevalence of various ocular infections seen in patients attending eye clinics in Karachi, Pakistan.

cells for adenovirus and HSV (DAROUGAR et al., 1984; 1985), and the other was kept for further investigations.

WALPITA et al.,

Results

Of the 388 patients investigated, 221 (57.0%) were men and 167 (43.0%) were women. The Figure shows the age distributions ‘of the patients in rela&n to their sex and the infections diagnosed. In the under 10 years old group significantly more female patients than male

Bacteria

m

Chlamydia

0

Adenovirus

m

HSV

Materials and Methods Patients and examination

This study was carried out in 3 eye hospitals in Karachi, the Layton Rahmatulla Benevolent Trust Base Eye Hospital at Korangi, the Spencer Eye Hospital,, and the Muslim Association Hospital. A total of 388 patients who attended the casualty departments of these hospitals during the period from November 1987to March 1988with various grades of conjunctivitis or keratoconjunctivitis was included in this study. All eyes were examined with a slit lamp. Symptoms and signs were graded on a scale of O-3 and recorded on a pro forma similar to that described previously (DAROUGAR et al., 1977). The severity of conjunctivitis was classified as mild, moderate or severeon the basis of the intensity of hyperaemia and papillary response(mild= 1, moderate= 2, and severe=3) in the palpebral conjunctiva. The final aetiological diagnosis of the diseasewas arrived at after consideration of the clinical observations together with the laboratory results. Many of these patients (273, 70.4%) had used some medication, either self-prescribed or prescribed by a pharmacist, before attending the eye hospital. Laborato y investigations

Bacteriology specimenswere collected by lightly swabbing the lower lid conjunctiva with a cotton-wool swab and plating on to blood-agar plates which were then incubated at 37°C. Specimensfor chlamydial and viral isolation were collected by swabbing the upper and lower lid conjunctivae as described previously (DAROUGAR & JONES, 1971). Swabs were placed in 2SP transport medium (GORDON et al., 1969) containing 3% inactivated calf serum and stored immediately in liquid nitrogen for transport to the laboratory in London. Each specimen was divided into 3 aliquots: one was cultured in McCoy cells treated with mitomycin C for Chlamydia trachomatis (WOODLAND et al., 1987), one was cultured in HEp2 *Presentaddress:Departmentof Animal Health, The Royal VeterinaryCollege,BoltonsPark,Hertfordshire,UK.

60

50

40

30 Male

20

IO

0

10

20

30 Female

40

50

60

Figure. Age distribution of patients (years) in relation to sex and infection diagnosed(HSV)=herpes simplex virus).

patients had bacterial infections (x2=4.2, Pl month Distribution Unilateral Bilateral Se;ve;;y

Chlamvdial

Number Adenovirus

1 (14%) 6 (86%)

177 (61%) 114 (39%)

of cases HSV”

Other

Total 221 (57.0%) 167 (43.0%) 323 (83.2%)

1 (14%) 6 (86%)

135 (46%) 156 (54%)

11 (16%)

Moderate Severe Source Korangi eye hospital Spencer eye hospital Muslim Association hospital Total

8 (3%) 88 (30%) 195 (67%)

71 (18.3%)

2 (28%)

203 (70%)

7 (1.8%)

291 (75.0%)

193 (49.7%) 195 (50.3%) 0 (0%)

5 (50%)

9 (2.3%)

24 (6.2%) 128 (33.0%) 236 (60.8%)

10 (2.6%)

388 (100%)

“Herpes simplex virus.

Discussion The 3 hospitals used for this study were situated in different areasof Karachi and catered for markedly different populations. The Korangi Base Eye Hospital was a charitable hospital situated in a suburb and was mainly used by poor people, the Spencer Eye Hospital was in the inner city area, serving a mostly middle classpopulation, and the Muslim Association Hospital was in the overcrowded old city, serving a predominantly business community. The results presented therefore represent a wide cross section of the population of Karachi. Large outbreaks of severe viral conjunctivitis frequently occur in Karachi during the hot humid period from April to October. This study was carried out during November to March and there was no evidence of a major epidemic of conjunctivitis during the period. The eye infections seen were therefore endemic in this community. Antibacterial drugs were freely available in the community and were frequently used before attendance at

Table 2. Bacteria and fungi grown from the eyes of patients with clinically diagnosed bacterial and adenoviras conjunctivitis Bacterial conjunctivitis Not done No growth

Adenovims conjunctivitis

Total

0

8

8

26

239 24

265 37 27

13 13 11

Staphylococcus aweus Staphylococcus albus

Non-haemolytic streptococci P-haemolytic streptococci

14 5

16

3 1

0 0

Diphtheroids

1 1

0 0

1 1 1

Comebacterium xerosis C&dida albicans

2 0

0

2

1 291

362

Streptococcus pneumoniae Haemophilus influenzae

Total

71

3

1

Table 3. Antibiotic resistance of ocular bacteria

Type of bacteria Staphylococcus aureus

Non-haemolytic streptococci P-haemolytic Streptococci Haemophilus influenme

Diphtheroids Totals

Number of isolates tested

Chloramphenicol

Penicillin

33 20

8 7

18

1 1 1

1 0 0

1 0 0 0

56

16

19

tive adenovirus caseshad either moderate or severeconjunctivitis. Altogether, bacteria were cultured from the eyes of 88 (22.7%) patients. 56 of the bacterial isolates were tested for sensitivity to a selection of the antibiotics commonly used in this community. The number of isolates resistant to these antibiotics is shown in Table 3. Nine of the patients in this study (2.3%) were suffering from HSV conjunctivitis, keratoconjunctivitis, or keratitis. All of these were unilateral and were either moderate or severe and 5 (55%) were of more than one week’s duration. The virus was isolated from only 4 cases. Only 7 patients (1.8%) were diagnosed as having chlamydial infections; 6 (86%) were female. Six cases(1 male and 5 females) were bilateral and 6 (1 male and 5 females) were confirmed by laboratory isolation.

Number of resistant isolates Bacitracin Neomycin Polymyxin 3 2

6

26

0 0 0

11 0 0 0

16 1 0 0

5

17

43

Tetracycline

Gentamicin

12 7

4

1 0 0

1 0 0

20

6

1

the hospital (unpublished data). This suggests that the frequency of bacterial conjunctivitis may have been underestimated, as many caseswhich had been treated with these drugs would probably have resolved without attending hospital. The patients who attended the clinics included many who had received no benefit from the prior treatment, as would be expected with most casesof viral conjunctivitis. However, this is similar to the situation in developed countries where many cases are treated by general practitioners and do not need to attend specialist eye clinics. Most of the casesof conjunctivitis seen in the clinics were caused by adenovirus. The highest prevalence of this infection was seenin male patients aged between 10 and 30 years. This is prdbably the most socially active group in the population of Karachi and they would

319 therefore be most at risk of contracting the diseasefrom their associates. The adenovirus isolation rate of 416% from the clinically diagnosed adenovirus casesor 31.2% from all the patients in the study was much higher than that observed in similar studies in London. An isolation rate of 8% was found in a study of acute conjunctivitis at Moorfields Eye Hosuital, London (WISHARTet al.. 1984). In another study of’infectious ‘conjunctivitis at’ anothkr hospital in London the adenovirus ‘isolation rate was 11.9% (bnpublished data). The higher adenovirus isolation rate in the present study may be accounted for by the severity of the infections seen in Karachi. Most of these cases were classed as moderate (30%) or severe (67%) and most presented during the first week of the disease(87%). It has been shown previously that the rate of virus‘isolaiion is high during the first week of disease,then falls during the second week, and is much lower for mild diseasethan for moderate or severedisease(GIBSONet al., 1979). Preliminary serotyping results indicated that most of the adenovirus isolates obtained in the present study were type 8 (unpublished data). Bacteria were cultured from the eyes of 88 of the patients (22.7%). This is much higher than the number of positive cultures obtained in an investigation of patients ittending an eye casualty department in-London (171226, 7.5%) (unnublished data) and is urobablv a reflection of the Ibier*standard of living a& hygiene in Karachi. Most casesof bacterial conjunctivitis occurred in children and teenagersand they were equally divided between males and females. The speciesof bacteria cultured from the eyes in this study were essentially similar to those cultured in London (Table 2). In 44 cases,bacteiia were cultured from the eyesof patients diagnosed as havina adenovirus infections. The bacteria Eown from the&cases were mainly staphylococci and it was assumed that these bacterial infections were secondary to primary viral infections. The growth of bacteria from the eye does not, therefore, exclude a concomitant viral infection. It was not clear from the results of this study whether the presence of bacteria increased the severity of an adenovirus eye infection, although all of the adenovirus cases with bacteria were classedas either moderate or severe. The bacteria isolated in this study showed a high degree of resistance to the antibiotics commonly used in this community to treat eye infections. Many of the patients studied had already obtained several types of antibiotic and/or steroid eye drops or ointment without prescription before attending the specialist eye clinics. However, the majority of them had not been able to apply the medicine correctly or to continue the course of treatment (unpublished data). Consequently, the treatment applied was generally inadequate and provided good conditions for the development of resistance to theseantibiotics. Chlamydial conjunctivitis was diagnosed in 1.8% of the patients in this study and C. trachbmatis was isolated from 1.5%. Sera from 4 of these patients contained antichlamydial antibodies which indicated an infection with the serotypes generally associatedwith trachoma (A to C) and 2 of the remainder had not developed any antichlamydial antibodies at the time of examination (unpublished data). No clinical evidence of typical active trachoma (follicular conjunctivitis with pannus and/or scars) was found in our patients. Signs of old trachoma with inactive pannus (vascularization without associatedcornea1 infiltration) and conjunctival scarring were seenin some older patients but were ignored for the purpose of this investigation. This suggests that trachoma is not a major problem in the urban population of Karachi, but that atypical trachoma caused by C. truchomatis serotypes A to C is present in the community. This is in accord with observations that, in developing countries, trachoma is less prevalent in urban than in rural populations (JONES, 1975; NICHOLASet al., 1967).

Only 2.3% of the patients in this study were suffering from HSV coniunctivitis. and the virus was isolated from only 1%. This is much ‘lower than figures which have been reported for developed countries. JONES(1959) reported that about 19% of acute conjunctivitis seen at Moorfields Eye Hospital, London, was caused by HSV. In another study in London, 21% of caseswith acute conjunctivitis who attended an eye casualty department were diagnosed as herpetic and HSV was isolated from 6% (WISHARTet al., 1984). In an investigation carried out in a hospital in London at the sametime as the present study, 17.2% of patients with moderate to severeconjunctivitis were diagnosed as hermetic and the rate of isoiation from these-patients was approximately 5.5% (unpublished data). Serological investigations of patients in Karachi have shown the presence of anti-HSV immunoglobulin G in about 80% of cases(unpublished data). This indicates that the majority of the population of Karachi have been exnosed to HSV infection and as a result many of them may-have developed someimmunity to the virus. Alternatively, the low proportion of HSV ocular infections seen in this study may reflect a higher incidence of other ocular infections in this community than in London. Acknowledgements We are grateful to the managements and doctors of the Layton-Rahmatulla Benevolent Trust Base Eye Hospital, the Spencer Eye Hospital and the Muslim Association Hospital, Karachi. We also thank Dr A. Ansari, Dr C. H. Chohan, Dr Qamar Khan, Dr Muneer Memon and Mr Graham Lavton for their help during the study, which was supported by-a grant from Dispersa AG, Switzerland. References Darougar, S. & Jones, B. R. (1971). Conjunctival swabbing for isolation of TRIC agent. BritishJournal of Ophthalmology, 55, 5R5-59n --_ _._.

Darougar, S., Viswalingam, M., Treharne, J. D., Kinnison, J. R. & Tones. B. R. 11977). Treatment of ‘TRIC’ infection of the ey; witg rifampicin 0; chloramphenicol. BritishJournal of Ophthalmology, 6$255-259. Darougar, S., Walplta, I’., Thaker, U., Viswalingam, N. & Wishart, M. S. (1984). Rapid culture test for adenovirus isolation. BritishJournal of Ophthalmology, 68,405-408. Darougar, S., Woodland, R. M. & Walpita, P. (1987). Value and cost effectiveness of double culture tests for diagnosis of ocular viral and chlamydial infections. British Journal of Ophthalmologv, 71,673-675. Darougar, S., Monnickendam, M. A. & Woodland, R. M. (1989). Management and prevention of ocular viral and chlamydial infections. CRC Critical Reviews in Microbiology, 16, X9-418.

Dart, J. K. H. (1986). Eye diseases at a community health centre. British Medical Yournal. 293.1477-1480. Gibson, J. A., Darouga< S:,,M&wiggan, D. A. & Thaker, U. (1979). Comparative sensitivity of a cultural test and the complement fEation test in the diagnosis of adenovirus ocular infection. BritishJournal of Ophthalmology, 63,617-620. Gordon, F. B., Harper, I. A., Quan, A. L., Treharne, J. D., Dwyer, R. StC. & Garland, J. A. (1969). Detection of chlamydia (bedsonia) in certain infections of man. I. Laboratory procedures: comparison of yolk sac and cell culture for detection and isolation. 3ournal of Infectious Diseases, 120,451-462. Jones, B. R. (1959). Management of ocular herpes. Transactions of the Ophthalmological Society of the United Kingdom, 79,425437.

Jones, B. R. (1975). The prevention of blindness from trachoma. Transactions of the Ophthalmological Society of the United Kingdom, 95, 16-33. Jones, N. P., Hayward, J. M., Khaw, I’. T., Claoue, C. M. P. & Elkinpton, A. R. (1986). Function of an ouhthahnic ‘accident and emergency’ department: results of a’ six month survey. British MedicalJournal, 292,18&190. Nichols, R. L., Bobb, A. A., Haddad,N. A. & McComb,D. E. (1967). Immunofluorescent studies of the microbiologic epidemiology of trachoma in Saudi Arabia. AmericanJournal ofOohthalmolow. 63.1372-1408. Wa?pi[a? I’., DaG;gac, S. & Thaker, U. (1985). A rapid and sensmve culture test for detecting herpes simplex virus from the eye. BritishJournal of Ophthalmology, 69,637-639. Wishart, P. K., James, C., Wishart, M. S. & Darougar, S.

320 (1984). Prevalence of acute conjunctivitis caused by chlamydia, adenovirus, and herpes simplex virus in an ophthalmic casualty department. British Journal of Ophthalmology, 68, 653-655.

Woodland, R. M., Kirton, R. P. & Darougar, S. (1987). Sensitivity of mitomycin-C treated McCoy cells for isolation of

TRANSACTIONS

OF THE ROYAL

Chlamydia trachomatisfrom genital specimens. EuropeanJournal of Clinical Microbiology, 6,653~656.

Received 8 May 1991; revised 16 June 1991; accepted for publication 8 August 1991

SOCIETYOF TROPICAL MEDICINE AND HYGIENE (1992) 86,320

-1 First fatal human case of Rift Valley fever in Madagascar Jacques Morvanl, Jean-Louis Lesbordesz, Pierre E. Rollins, Jean-Claude Moudenl and Jean Roux1 ‘Institut Pasteur, BP. 1274, Tananarive, Madagascar; Xlinique Me’dzcale, H6pital Militaire, Tananarive, Madagascar; 3Institut Pasteur, 25 rue du Dr Roux, 75015 Paris, France Although Rift valley fever (RVF) epizootics have occurred in East and South Africa since the beginning of the century, RVF virus was not known in Madagascar until 1979 when it was isolated from a pool of mosquitoes and subsequently from an uncomplicated human case after a laboratorv accident (MATHIOT et al.. 1984’1. Antigenic analysis using mondclonal antibodies ievealeh that the Madagascar strains were more closely related to the highly pa&ogenic Egyptian epizootic strain (involved in the 1977-1978 outbreak) than to anv other enzootic African strain (SALUZZOet hZ., 1989). 1; spite of the apparent presence of RVF in potential vectors, no RVF outbreak was reported among the susceptible livestock (mainly cattle) and human populations. However in March, 1990, during the rainy season (December to March), a high incidence of abortion in cattle was reported from the east coast of Madagascar surrounding the city of Feverive, and recent RVF virus circulation was confirmed by the presence of immunoglobulin M (IFZM) antibodies in cattle and human. though no virus isilat’lon was made (MORVAN et al., 199’1). Since January 1991, numerous foci of bovine abortion were reported in the central highlands of Madagascar where cattle numbers are high and movements of cattle are frequent (J. Morvan, unpublished data). In February 1991, a 36 year old woman was admitted to the Military Hospital of Antananarivo with a history of fever, jaundice of 2 d duration and sudden onset of neurological symptoms (disorientation and coma). The following day, she died with hepatoencephalonephritis, without haeaminotransferase morrhagic symptoms (aspartate 2700 iu, alanine aminotransferase 20 040 iu, serum creatinine 1750 pmol/litre, prothrombin time 22% , platelets count 194 999imm. haemoelobin 12 ~1. A serum samnle taken upon admission to thi hospital &owed a high Ieke

of RVF specific IgM and RVF virus antigen detected by immunocapture enzyme-linked immunosorbent assay. RVF virus was isolated in Vero cells. A liver biopsy the day before death showed extensive necrosis of liver hepatocytes cells with Councilman bodies and inflammatory cell infiltration. Epidemiological studies showed that the patient had not been directly involved in animal caretaking but she lived 1 km from a cattle farm where an RVF outbreak had been reported. Several strains of RVF were isolated from bovine abortion products and IgM prevalence was very high: lWl1 (90.9%) in recovering aborting females and in 57/172 (36.6%) in other cattle. Using a panel of monoclonal antibodies (kindly provided by J. F. Smith, Virology Division, USAMRIID, USA), the human and bovine isolates were tvped and all were found to be identical. All were recognized by an antinucleocapsid monoclonal antibodv (RlP3E71. like the non-Eavntian African strains but &like the 1599 Madagascar mG;uito isolate (SALUZZOet al., 1989). This result suggest either recent introduction and subsequent epidemic-spread of an African RVF virus. or the uresence of 2 antigenicallv different viruses in the same geographical area. ko oth& human case was reported, but IgM antibodies were detected in some other inhabitants-of the patient’s village 1121166. 7.2%). Mosauitoes were caught during 2 nights h the batieni’s home surroundings ~=2200,-84.S”~ of which were Culex antennatus), but no virus was isolated from these potential vectors. Serological investigation of 135 patients with fever in the same hospital, between January and March 1991, showed onlv one IZM nositive natient. More studies will be done to &aluatgthehuman impact of this outbreak. References Mathiot, C., Ribot, J. J., Clerc, Y., Coulanges, P. & Rasalofonirina. N. (1984). Fievre de la vall6e du Rift et virus Zinaa: un a&ovir& paihogene pour l’homme et l’animal nouv&u pour Madagascar. Archives de l’lnstitut Pasteur de Madagascar, 51,125-134.

Morvan, J., Fontenille, D., Saluzzo, J. F. & Coulanges, I’. 11991).Possible Rift Vallev fever outbreak in man and cattle in Midagascar. Transactioks of the Royal Society of Tropical Medicine and Hygiene, 85, 108. Saluzzo, J.-F., Anderson, G. W:, jr, Smith, J. F., Fonrenille, D. & Coulange!, P. (1989). Biological and antigenic relationship between Rift Valley fever virus strains isolated in Egypt and Madagascar. Transactions of the Royal Society of Tropical Medicine and Hygiene, 83,701,

Received 6 September 1991; revised 9 January 1992; acceptedfor publication 1SJanuary 1992