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Chuang YH, Wang YC, Yen CY, Lin CC, Chen CC. Case Series: Unusual Presentation of Acanthamoeba Coinfection in the Cornea. Optom Vis Sci 2022; 99:605-611. [PMID: 35413026 PMCID: PMC9296050 DOI: 10.1097/opx.0000000000001906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE The cases illustrate Acanthamoeba coinfection with Pseudomonas aeruginosa or microsporidia in the cornea. PURPOSE This case series aimed to alert clinicians toward considering Acanthamoeba coinfection in the cornea when unusual presentation such as perineuritis or epitheliitis was observed in clinical images. Increased suspicion of Acanthamoeba coinfection may facilitate early diagnosis and prompt management, eventually leading to good vision outcomes. CASE SERIES An 11-year-old boy wearing orthokeratology lens for myopia control complained of pain in the right eye for 1 week. A paracentral corneal ulcer with perineuritis was observed. Culture from corneal tissue revealed P. aeruginosa , and an in vivo confocal microscopic examination showed highly reflective and oval-shaped structures indicating Acanthamoeba coinfection. Corneal lesions gradually improved under 0.02% polyhexamethylene biguanidine, 0.1% propamidine isethionate, and 0.3% ciprofloxacin. At 1 year, the final best-corrected visual acuity was 20/25 with residual paracentral corneal opacity. Another 20-year-old man complained of pain in the right eye for 2 weeks. Multiple raised corneal lesions associated with epitheliitis were found. Moreover, 1% acid-fast staining showed oval-shaped spores, and microsporidia infection was inferred. In addition, polymerase chain reaction results obtained after subjecting the patient to corneal debridement revealed positivity for Acanthamoeba . Polyhexamethylene biguanidine (0.02%) and 0.5% moxifloxacin were prescribed, and the lesions subsided. At a 2-year follow-up, the final best-corrected visual acuity was 20/25. CONCLUSIONS Perineuritis in orthokeratology lens wearers and epitheliitis without any predisposing factor are unusual presentations of Acanthamoeba coinfection in the cornea. These corneal findings should arouse the suspicion of coinfection and enable the clinicians to conduct the appropriate workup and initiate adequate treatment. This case series demonstrated that early diagnosis and prompt treatment can improve visual prognosis.
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Affiliation(s)
- Yu-Hsun Chuang
- Department of Ophthalmology, Taipei City Hospital, Renai Branch, Taipei, Taiwan
| | - Ying-Ching Wang
- Department of Ophthalmology, Taipei City Hospital, Renai Branch, Taipei, Taiwan
| | - Chu-Yu Yen
- Department of Ophthalmology, Taipei City Hospital, Renai Branch, Taipei, Taiwan
| | - Chih-Chung Lin
- Department of Ophthalmology, Taipei City Hospital, Renai Branch, Taipei, Taiwan
| | - Chun-Chen Chen
- Department of Ophthalmology, Taipei City Hospital, Renai Branch, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Abstract
Microsporidia are obligate intracellular pathogens identified ∼150 years ago as the cause of pébrine, an economically important infection in silkworms. There are about 220 genera and 1,700 species of microsporidia, which are classified based on their ultrastructural features, developmental cycle, host-parasite relationship, and molecular analysis. Phylogenetic analysis suggests that microsporidia are related to the fungi, being grouped with the Cryptomycota as a basal branch or sister group to the fungi. Microsporidia can be transmitted by food and water and are likely zoonotic, as they parasitize a wide range of invertebrate and vertebrate hosts. Infection in humans occurs in both immunocompetent and immunodeficient hosts, e.g., in patients with organ transplantation, patients with advanced human immunodeficiency virus (HIV) infection, and patients receiving immune modulatory therapy such as anti-tumor necrosis factor alpha antibody. Clusters of infections due to latent infection in transplanted organs have also been demonstrated. Gastrointestinal infection is the most common manifestation; however, microsporidia can infect virtually any organ system, and infection has resulted in keratitis, myositis, cholecystitis, sinusitis, and encephalitis. Both albendazole and fumagillin have efficacy for the treatment of various species of microsporidia; however, albendazole has limited efficacy for the treatment of Enterocytozoon bieneusi. In addition, immune restoration can lead to resolution of infection. While the prevalence rate of microsporidiosis in patients with AIDS has fallen in the United States, due to the widespread use of combination antiretroviral therapy (cART), infection continues to occur throughout the world and is still seen in the United States in the setting of cART if a low CD4 count persists.
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Szentmáry N, Shi L, Daas L, Seitz B. Diagnostics and management approaches for Acanthamoeba keratitis. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1791081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Nóra Szentmáry
- Dr. Rolf M. Schwiete Center for Limbal Stem Cell and Aniridia Research, Saarland University, Homburg/Saar, Germany
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Lei Shi
- Department of Ophthalmology, Saarland University Medical Center, UKS, Homburg/Saar, Germany
| | - Loay Daas
- Department of Ophthalmology, Saarland University Medical Center, UKS, Homburg/Saar, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, UKS, Homburg/Saar, Germany
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Khurana S, Sharma M. Parasitic keratitis - An under-reported entity. Trop Parasitol 2020; 10:12-17. [PMID: 32775286 PMCID: PMC7365502 DOI: 10.4103/tp.tp_84_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/12/2020] [Accepted: 01/20/2020] [Indexed: 11/04/2022] Open
Abstract
Parasitic keratitis (PK) is unique entity among parasitic infections where corneal involvement could result from direct inoculation of the parasite via exogenous environment or spread via endogenous neighboring organs or as a result of immune-mediated damage secondary to a systemic parasitic infection. Most cases of PK are caused by Acanthamoeba spp. and Microsporidia spp. though few other parasitic agents can also lead to corneal involvement. Mimicking as other infectious and non-infectious causes of keratitis, PK often escapes detection. This review summarizes the predominant causes of PK along with the epidemiological, clinical and microbiological details of each. Though several gaps exist in our understanding of the prevalence of PK, the one thing for sure is that PK is on the rise. With advanced diagnostic modalities and enough literature on optimal management of cases of PK, it is now imperative that a strong clinical suspicion of PK is kept when examining a case of corneal pathology and adequate investigations are ordered.
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Affiliation(s)
- Sumeeta Khurana
- Department of Medical Parasitology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Megha Sharma
- Department of Medical Parasitology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Heyworth MF. Molecular diagnosis of human microsporidian infections. Trans R Soc Trop Med Hyg 2019; 111:382-383. [PMID: 29244189 DOI: 10.1093/trstmh/trx070] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/31/2017] [Indexed: 11/13/2022] Open
Abstract
With the transformation of HIV infection from an acutely life-threatening disease into a chronic condition (as a consequence of the development of effective antiretroviral medication), the perceived clinical importance of diagnosing and treating microsporidian infections diminished, at least in industrialized countries. In locales where effective antiretroviral therapy is not available, as well as in patients with immunodeficiency for reasons other than HIV infection (e.g., following organ transplantation), and in individuals with suspected ocular microsporidiosis, diagnosing microsporidian infections remains a clinical priority. Molecular techniques can readily distinguish different species of microsporidia. At least one molecular diagnostic platform that can detect the intestinal parasites Encephalitozoon intestinalis and Enterocytozoon bieneusi is commercially available.
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Affiliation(s)
- Martin F Heyworth
- Research Service (151), Corporal Michael J. Crescenz Department of Veterans Affairs (VA) Medical Center, University and Woodland Avenues, Philadelphia, PA 19104, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Huang FC, Hsieh HY, Chang TC, Su SL, Tseng SL, Lai YH, Kuo MT. A DNA dot hybridization model for molecular diagnosis of parasitic keratitis. Mol Vis 2017; 23:614-623. [PMID: 28867932 PMCID: PMC5568909 DOI: pmid/28867932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 08/22/2017] [Indexed: 02/08/2023] Open
Abstract
Purpose Developing a DNA dot hybridization model for diagnosing parasitic keratitis. Methods Newly designed oligonucleotide probes for detecting Acanthamoeba and microsporidia were tested with target reference strains of Acanthamoeba (n = 20) and microsporidia (n = 3), and non-target microorganisms, including bacteria (n = 20) and fungi (n = 20). These probes, which had passed the preliminary tests, were then assembled as a parasite dot hybridization (PDH) model for assessing 33 clinical samples from patients with clinically suspected Acanthamoeba and microsporidia keratitis, including eight positives for Acanthamoeba, 13 positives for microsporidia, and 12 negatives for both pathogens. Results Two probes for detecting Acanthamoeba and two for detecting microsporidia passed the tests using target and non-target strains and then were assembled in the PDH model. For clinical samples, one Acanthamoeba-positive sample (proved with pathology) was falsely negative according to the PDH assay. The sensitivity and specificity of the PDH assay for diagnosing Acanthamoeba keratitis were 87.5% and 100%, respectively, while the sensitivity and specificity for diagnosing microsporidia keratitis were 100%. The infectious agent of all clinical samples of microsporidia keratitis was identified as Vittaforma corneae with DNA sequencing, while those of Acanthamoeba keratitis were caused by four species of Acanthamoeba, with Acanthamoeba castellanii found in four samples (50%, 4/8). Conclusions The PDH model has the potential to be a molecular assay for diagnosing Acanthamoeba and microsporidia keratitis. However, a prospective clinical study might be needed before the model is adopted in routine clinical practice.
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Affiliation(s)
- Fu-Chin Huang
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsin-Yi Hsieh
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsung C Chang
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shu-Li Su
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shin-Ling Tseng
- Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Hsuan Lai
- Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ming-Tse Kuo
- Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Haas CN. Microbial dose response modeling: past, present, and future. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2015; 49:1245-59. [PMID: 25545032 DOI: 10.1021/es504422q] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The understanding of the risk to humans from exposure to pathogens has been firmly put into a risk assessment framework. A key element of applying this approach is the understanding of the relationship between dose and response for particular pathogens. This understanding has progressed from early use of threshold concepts ("minimal infectious dose") thru multiple generations of models. Generation 1 models describe probability of response to exposed dose. Generation 2 models incorporate host factors (e.g., age) and/or pathogen factors (e.g., particle size of inhaled agents). Generation 3 models describe the rate at which effects develop, i.e. the epidemic curve. These (generation 1 through three models) have been developed and used in multiple contexts. Beyond Generation 3 lies an opportunity for the deep incorporation of in vivo physiological responses and the coupling of the individual host dynamics to the dynamics of spread of contagious diseases in the population. This would enable more direct extrapolation from controlled dosing studies to estimate population level effects. There remain also needs to understand broader categories of infectious agents, including pathogenic amoebae and fungi. More advanced models need to be validated against well-characterized human outbreak data.
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Affiliation(s)
- Charles N Haas
- Department of Civil, Architectural & Environmental Engineering Drexel University Philadelphia, Pennsylvania 19104, United States
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Tu EY, Shoff ME, Gao W, Joslin CE. Effect of low concentrations of benzalkonium chloride on acanthamoebal survival and its potential impact on empirical therapy of infectious keratitis. JAMA Ophthalmol 2013; 131:595-600. [PMID: 23519403 DOI: 10.1001/jamaophthalmol.2013.1644] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The significant antiacanthamoebal effect of benzalkonium chloride, at or below concentrations used for preservation of common ophthalmic preparations, should be understood both when choosing empiric antibiotic therapy for infectious keratitis and when assessing the persistent rise in Acanthamoeba cases in the United States since 2003. OBJECTIVE To characterize the antiacanthamoebal efficacy of low concentrations of benzalkonium chloride (BAK) for drug preservation and therapeutic effect against Acanthamoeba. DESIGN Experimental study with a review of the literature. SETTING Laboratory. EXPOSURES A concentration of 10(4) trophozoites of 3 well-characterized clinical strains of Acanthamoeba were exposed at 0.5, 2.0, 3.5, 5.0, and 6.5 hours to BAK (0.001%, 0.002%, and 0.003%), moxifloxacin hydrochloride (0.5%), and moxifloxacin (0.5%) + BAK (0.001% and 0.003%) with hydrogen peroxide (3%) and amoeba saline controls. MAIN OUTCOMES AND MEASURES Amoeba survival was calculated using the most probable number method recorded as log kill values. The relationship of BAK concentration and exposure time as well as the relative effect of BAK and moxifloxacin on acanthamoebal survival were analyzed. RESULTS Amoebicidal activity of BAK is both time dependent and concentration dependent in pooled and strain-stratified analyses (P < .001). Moxifloxacin demonstrated no significant independent inhibitory effect or additive effect to BAK efficacy on acanthamoebal survival. The profound antiacanthamoebal effect of BAK, 0.003%, was similar to that of hydrogen peroxide for certain strains. CONCLUSIONS AND RELEVANCE Low concentrations of BAK, previously demonstrated to concentrate and persist in ocular surface epithelium, exhibit significant antiacanthamoebal activity in vitro at or below concentrations found in commercially available ophthalmic anti-infectives. The unexplained persistence of the Acanthamoeba keratitis outbreak in the United States, clusters abroad, and clinical studies reporting resolution or modification of Acanthamoeba keratitis without specific antiacanthamoebal therapy suggests that other contributing factors should be considered, including changes in the formulations used for empirical therapy of presumed infectious keratitis occurring in the same period.
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Affiliation(s)
- Elmer Y Tu
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Pacella E, La Torre G, De Giusti M, Brillante C, Lombardi AM, Smaldone G, Lenzi T, Pacella F. Results of case-control studies support the association between contact lens use and Acanthamoeba keratitis. Clin Ophthalmol 2013; 7:991-4. [PMID: 23761962 PMCID: PMC3673962 DOI: 10.2147/opth.s43471] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acanthamoeba keratitis (AK) is ever more frequently reported in industrialized countries. The loss of the corneal surface integrity consequent to secondary microtrauma produced by the use of contact lens (CL) favors the penetration of the parasite into the corneal tissue. OBJECTIVES A scientific review was performed to investigate the association of CL wear as an Acanthamoeba keratitis (AK) risk factor. METHODS A computerized screening of 7834 Medline articles (4623 from PubMed; 3211 from Scopus) used a strict selection criteria of case-control studies involving CL wear and/or trauma. RESULTS The search yielded five case-control studies published from 1995 to 2012. All studies included showed a statistically significant positive association between AK and CL use, with a combined odds ratio (OR) of 10.21 (95%, confidence intervals [CI]; 3.57-27.64). STATISTICAL ANALYSIS All studies included showed a statistically significant positive association between AK and CL use, though with differing OR values. CONCLUSION Though rare, AK should be held in higher consideration when ophthalmologists are faced with CL users exhibiting simplex-like lesions associated with circular stromal infiltrates and disproportionate ocular pain in respect to the objective clinical picture.
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Affiliation(s)
- Elena Pacella
- Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Italy
| | - Giuseppe La Torre
- Department of Public Health and Infectious Diseases, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Italy
| | - Maria De Giusti
- Department of Public Health and Infectious Diseases, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Italy
| | - Chiara Brillante
- Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Italy
| | - Anna Maria Lombardi
- Department of Public Health and Infectious Diseases, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Italy
| | - Gianpaolo Smaldone
- Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Italy
| | - Tommaso Lenzi
- Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Italy
| | - Fernanda Pacella
- Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Italy
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Bi YL, Bock F, Zhou Q, Cursiefen C. Recurrent interface abscess secondary to Acanthamoeba keratitis treated by deep anterior lamellar keratoplasty. Int J Ophthalmol 2012; 5:774-5. [PMID: 23275916 DOI: 10.3980/j.issn.2222-3959.2012.06.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 11/15/2012] [Indexed: 11/02/2022] Open
Affiliation(s)
- Yan-Long Bi
- Department of Ophthalmology, Tongji Hospital affiliated to Tongji University School of Medicine, Shanghai 200065, China
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