Acanthamoeba keratitis in New Zealand, including two cases with in vivo resistance to polyhexamethylene biguanide

Acanthamoeba keratitis and contact lens wear

Acanthamoeba keratitis is a rare but serious complication of contact lens wear that may cause severe visual loss. The clinical picture is usually characterised by severe pain, sometimes disproportionate to the signs, with an early superficial keratitis that is often misdiagnosed as herpes simplex virus (HSV) keratitis. Advanced stages of the infection are usually characterised by central corneal epithelial loss and marked stromal opacification with subsequent loss of vision. In this paper, six cases of contact lens-related Acanthamoeba keratitis that occurred in Australia and New Zealand over a three-year period are described. Three of the patients were disposable soft lens wearers, two were hybrid lens wearers and one was a rigid gas permeable lens wearer. For all six cases, the risk factors for Acanthamoeba keratitis were contact lens wear with inappropriate or ineffective lens maintenance and exposure of the contact lenses to tap or other sources of water. All six patients responded well to medical therapy that involved topical use of appropriate therapeutic agents, most commonly polyhexamethylene biguanide and propamidine isethionate, although two of the patients also subsequently underwent deep lamellar keratoplasty due to residual corneal surface irregularity and stromal scarring. Despite the significant advances that have been made in the medical therapy of Acanthamoeba keratitis over the past 10 years, prevention remains the best treatment and patients who wear contact lenses must be thoroughly educated about the proper use and care of the lenses. In particular, exposure of the contact lenses to tap water or other sources of water should be avoided.

PLGA nanoparticles loaded with Gallic acid- a constituent of Leea indica against Acanthamoeba triangularis

Acanthamoeba, a genus that contains at least 24 species of free-living protozoa, is ubiquitous in nature. Successful treatment of Acanthamoeba infections is always very difficult and not always effective. More effective drugs must be developed, and medicinal plants may have a pivotal part in the future of drug discovery. Our research focused on investigating the in vitro anti- acanthamoebic potential of Leea indica and its constituent gallic acid in different concentrations. Water and butanol fractions exhibited significant amoebicidal activity against trophozoites and cysts. Gallic acid (100 µg/mL) revealed 83% inhibition of trophozoites and 69% inhibition of cysts. The butanol fraction induced apoptosis in trophozoites, which was observed using tunnel assay. The cytotoxicity of the fractions and gallic acid was investigated against MRC-5 and no adverse effects were observed. Gallic acid was successfully loaded within poly (D,L-lactide-co-glycolide) (PLGA) nanoparticles with 82.86% encapsulation efficiency, while gallic acid showed 98.24% in vitro release at 48 hours. Moreover, the gallic acid encapsulated in the PLGA nanoparticles exhibited 90% inhibition against trophozoites. In addition, gallic acid encapsulated nanoparticles showed reduced cytotoxicity towards MRC-5 compared to gallic acid, which evidenced that natural product nanoencapsulation in polymeric nanoparticles could play an important role in the delivery of natural products.

Drug Discovery against Acanthamoeba Infections: Present Knowledge and Unmet Needs

Although major strides have been made in developing and testing various anti-acanthamoebic drugs, recurrent infections, inadequate treatment outcomes, health complications, and side effects associated with the use of currently available drugs necessitate the development of more effective and safe therapeutic regimens. For any new anti-acanthamoebic drugs to be more effective, they must have either superior potency and safety or at least comparable potency and an improved safety profile compared to the existing drugs. The development of the so-called 'next-generation' anti-acanthamoebic agents to address this challenge is an active area of research. Here, we review the current status of anti-acanthamoebic drugs and discuss recent progress in identifying novel pharmacological targets and new approaches, such as drug repurposing, development of small interfering RNA (siRNA)-based therapies and testing natural products and their derivatives. Some of the discussed approaches have the potential to change the therapeutic landscape of Acanthamoeba infections.

The Antifungal Drug Isavuconazole Is both Amebicidal and Cysticidal against Acanthamoeba castellanii

Current treatments for Acanthamoeba keratitis rely on a combination of chlorhexidine gluconate, propamidine isethionate, and polyhexamethylene biguanide. These disinfectants are nonspecific and inherently toxic, which limits their effectiveness. Furthermore, in 10% of cases, recurrent infection ensues due to the difficulty in killing both trophozoites and double-walled cysts. Therefore, development of efficient, safe, and target-specific drugs which are capable of preventing recurrent Acanthamoeba infection is a critical unmet need for averting blindness. Since both trophozoites and cysts contain specific sets of membrane sterols, we hypothesized that antifungal drugs targeting sterol 14-demethylase (CYP51), known as conazoles, would have deleterious effects on A. castellanii trophozoites and cysts. To test this hypothesis, we first performed a systematic screen of the FDA-approved conazoles against A. castellanii trophozoites using a bioluminescence-based viability assay adapted and optimized for Acanthamoeba The most potent drugs were then evaluated against cysts. Isavuconazole and posaconazole demonstrated low nanomolar potency against trophozoites of three clinical strains of A. castellanii Furthermore, isavuconazole killed trophozoites within 24 h and suppressed excystment of preformed Acanthamoeba cysts into trophozoites. The rapid action of isavuconazole was also evident from the morphological changes at nanomolar drug concentrations causing rounding of trophozoites within 24 h of exposure. Given that isavuconazole has an excellent safety profile, is well tolerated in humans, and blocks A. castellanii excystation, this opens an opportunity for the cost-effective repurposing of isavuconazole for the treatment of primary and recurring Acanthamoeba keratitis.

Ursolic Acid Derivatives as Potential Agents Against Acanthamoeba Spp

The current chemotherapy of Acanthamoeba keratitis relies on few drugs with low potential and limited efficacy, for all this there is an urgent need to identify new classes of anti-Acanthamoeba agents. In this regard, natural products play an important role in overcoming the current need and medicinal chemistry of natural products represents an attractive approach for the discovery and development of new agents. Ursolic acid, a natural pentacyclic triterpenoid compound, possesses a broad spectrum of activities including anti-Acanthamoeba. Herein, we report on the development by chemical transformation of an ursolic acid-based series of seven compounds (2-8), one of them reported for the first time. The structure-activity relationship (SAR) analysis of their anti-Acanthamoeba activity revealed that acylation/ether formation or oxidation enhances their biological profile, suggesting that the hydrophobic moiety contributes to activity, presumably by increasing the affinity and/or cell membrane permeability. These ursolic acid derivatives highlight the potential of this source as a good base for the development of novel therapeutic agents against Acanthamoeba infections.

The Development of Drugs against Acanthamoeba Infections

For the past several decades, there has been little improvement in the morbidity and mortality associated with Acanthamoeba keratitis and Acanthamoeba encephalitis, respectively. The discovery of a plethora of antiacanthamoebic compounds has not yielded effective marketed chemotherapeutics. The rate of development of novel antiacanthamoebic chemotherapies of translational value and the lack of interest of the pharmaceutical industry in developing such chemotherapies have been disappointing. On the other hand, the market for contact lenses/contact lens disinfectants is a multi-billion-dollar industry and has been successful and profitable. A better understanding of drugs, their targets, and mechanisms of action will facilitate the development of more-effective chemotherapies. Here, we review the progress toward phenotypic drug discovery, emphasizing the shortcomings of useable therapies.

Artemisia annua L. as a plant with potential use in the treatment of acanthamoebiasis

The treatment of acanthamoebiasis is a great problem. Most cerebral invasions end with death, and the treatment of ocular invasions is usually long-lasting and not very effective. Numerous plant extracts and substances isolated from plants, which are effective against trophozoites or cysts, have been studied in the treatment of acanthamoebiasis. However, no agents that are simultaneously effective against both developing forms of amoebae have been discovered yet. It seems that such a plant which fulfils both tasks is Artemisia annua L. Our studies showed that water, alcohol and chloroform extracts from the herb A. annua L. can be applied in general and local treatment or in combined therapy with antibiotics in the treatment of acanthamoebiasis. Extracts from this plant show not only in vitro but also in vivo effects. Studies carried out on experimental animals infected with amoebae show that the application of these extracts significantly prolongs the survival of the animals.

Evaluation of the activity of new cationic carbosilane dendrimers on trophozoites and cysts of Acanthamoeba polyphaga

Dendrimers are repetitively branched molecules with a broad spectrum of applications, mainly for their antimicrobial properties and as nanocarriers for other molecules. Recently, our research group have synthesized and studied their activity against Acanthamoeba sp., causative agent of a severe ocular disease in humans: Acanthamoeba keratitis. New cationic carbosilane dendrimers were tested against the protozoa forms at different concentrations and for different incubation times. Trophozoite viability was determined by manual counting and cyst viability by observing excystment in microplates with fresh culture medium. Cytotoxicity was checked on HeLa cells using the microculture tetrazolium assay. Alterations were observed by optical microscopy and by flow cytometry staining with propidium iodide. Six out of the 18 dendrimers tested were non-cytotoxic and effective against the trophozoite form, having one of them (dendrimer 14 with an IC50 of 2.4 + 0.1 mg/L) a similar activity to chlorhexidine digluconate (IC50 1.7 + 0.1 mg/L). This dendrimer has a polyphenoxo core and a sulphur atom close to the six -NH3+ terminal groups. On the other hand, only two dendrimers showed some effect against cysts (dendrimers 14 and 17). However, their minimum cysticidal concentrations were cytotoxic and less effective than the control drug. The alterations on the amoeba morphology produced by the treatment with dendrimers were size reduction, increased complexity, loss of acanthopodia and cell membrane disruption. In conclusion, these results suggest that some dendrimers may be studied in animal models to test their effect and that new dendrimers with similar features should be synthesized.

Role of protease-activated receptors 2 (PAR2) in ocular infections and inflammation

Protease-activated receptors (PARs) belong to a unique family of G protein-coupled receptors (GPCRs) that are cleaved at an activation site within the N-terminal exodomain by a variety of proteinases, essentially of the serine (Ser) proteinase family. After cleavage, the new N-terminal sequence functions as a tethered ligand, which binds intramolecularly to activate the receptor and initiate signaling. Cell signals induced through the activation of PARs appear to play a significant role in innate and adoptive immune responses of the cornea, which is constantly exposed to proteinases under physiological or pathophysiological conditions. Activation of PARs interferes with all aspects of the corneal physiology such as barrier function, transports, innate and adoptive immune responses, and functions of corneal nerves. It is not known whether the proteinase released from the microorganism can activate PARs and triggers the inflammatory responses. The role of PAR2 expressed by the corneal epithelial cells and activation by serine protease released from microorganism is discussed here. Recent evidences suggest that activation of PAR2, by the serine proteinases, play an important role in innate and inflammatory responses of the corneal infection.

Anti-amoebic properties of carbonyl thiourea derivatives

Thiourea derivatives display a broad spectrum of applications in chemistry, various industries, medicines and various other fields. Recently, different thiourea derivatives have been synthesized and explored for their anti-microbial properties. In this study, four carbonyl thiourea derivatives were synthesized and characterized, and then further tested for their anti-amoebic properties on two potential pathogenic species of Acanthamoeba, namely A. castellanii (CCAP 1501/2A) and A. polyphaga (CCAP 1501/3A). The results indicate that these newly-synthesized thiourea derivatives are active against both Acanthamoeba species. The IC50 values obtained were in the range of 2.39-8.77 µg·mL⁻¹ (9.47-30.46 µM) for A. castellanii and 3.74-9.30 µg·mL⁻¹ (14.84-31.91 µM) for A. polyphaga. Observations on the amoeba morphology indicated that the compounds caused the reduction of the amoeba size, shortening of their acanthopodia structures, and gave no distinct vacuolar and nuclear structures in the amoeba cells. Meanwhile, fluorescence microscopic observation using acridine orange and propidium iodide (AOPI) staining revealed that the synthesized compounds induced compromised-membrane in the amoeba cells. The results of this study proved that these new carbonyl thiourea derivatives, especially compounds M1 and M2 provide potent cytotoxic properties toward pathogenic Acanthamoeba to suggest that they can be developed as new anti-amoebic agents for the treatment of Acanthamoeba keratitis.

Evaluation of inhibitory potential of some selective methanolic plants extracts on biological characteristics of Acanthamoeba castellanii using human corneal epithelial cells in vitro

Acanthamoeba is an opportunistic protozoan pathogen and known to be one of the most ubiquitous organisms, play a vital role in ecosystem, and recognized to cause blinding keratitis and rare but fatal granulomatous encephalitis involving the central nervous system with a very poor prognosis. This is due to limited availability of effective anti-Acanthamoeba drugs. The objective of the present study was to determine the efficacy of methanolic plants crude extracts on the viability and biological properties of Acanthamoeba castellanii (T4 genotype) and its cytotoxic effects on human corneal epithelial cells (HCEC). Using HCEC, it was observed that Acanthamoeba exhibited binding (>90 %) and cytotoxicity (>80 %) to host cells. However, plant crude extracts remarkably inhibited more than 70 and 60 % of Acanthamoeba binding and cytotoxicity to HCEC, respectively. It was further established that crude extracts (ranging from 0.1 to 1.5 mg/ml) exhibited amoebicidal effects, i.e., >50 % of trophozoites were killed/reduced at maximum dose (1.5 mg/ml) within 1 h incubation. However, the residual subpopulation remained static over longer incubations. Furthermore, growth assay demonstrated crude extracts inhibited >50 % Acanthamoeba numbers up to 7 days. Our results confirmed that plant crude extracts has inhibitory effects on Acanthamoeba growth and viability. Overall, these findings revealed that tested plant extracts is inhibitory to Acanthamoeba properties associated with pathogenesis. To the best of our knowledge, our findings demonstrated for the first time that selected methanol plant crude extracts exhibits inhibitory effects on biological properties of Acanthamoeba without any toxic effects on HCEC cells in vitro.

Contact lens-related acanthamoeba keratitis

Acanthamoeba keratitis is a rare but severe disease, with more than 95% of cases occurring in contact lens wearers. With a worldwide resurgence of contact lens-related disease, this report illustrates the clinical characteristics and treatment challenges representative of this disease. This report describes Acanthamoeba keratitis in a 47-year-old female using extended wear silicone hydrogel contact lenses, with a history of swimming in a home pool and failure to subsequently disinfect the contact lenses. The diagnosis was based on clinical signs, disease course, and confocal microscopy results despite a negative result for corneal smear and culture. The corneal signs included an epithelial defect, epithelial irregularities, anterior stromal infiltrates, perineural infiltrates, an anterior stromal ring infiltrate, and hypopyon. The case was diagnosed as an infective keratitis and treated promptly using intensive topical administration of fortified gentamicin and cephalothin. The high likelihood Acanthamoeba prompted immediate use of polyhexamethylbiguanide and chlorhexidine, with propamide and adjunct treatment using atropine and oral diclofenac. Steroids were added on day 3, and the frequency of administration of antibacterial treatment was gradually reduced and ceased by day 10. The analgesia was stopped at 3 months. The frequency of administration of antiamoeba therapy and steroid treatment was slowly reduced and all treatment was ceased after 18 months. Despite considerable morbidity in terms of the treatment duration, hospitalization, outpatient appointments, and associated disease costs, the final visual outcome (6/6) was excellent.

Resurgence of Acanthamoeba keratitis in Auckland, New Zealand: a 7-year review of presentation and outcomes

PURPOSE

To investigate the presentation, clinical characteristics and outcomes of Acanthamoeba keratitis (AK) in Auckland, New Zealand over a 7-year period.

METHODS

Retrospective analysis of all cases of AK treated by the tertiary corneal service at Auckland City Hospital/ University of Auckland Department of Ophthalmology (August 2001 to May 2008). Data were collected regarding age, gender, contact lens history, presenting signs and symptoms, diagnosis at first presentation, time to final diagnosis, identifiable risk factors, presenting and final visual acuity, results of microbiological testing, medical treatment, surgical interventions, recurrence of disease and length of follow up. All photographs and in vivo confocal microscopy images were reviewed.

RESULTS

Twenty-five eyes of 25 patients were identified with a diagnosis of AK (mean age 40 +/- 13 years). Ninety-six per cent were contact lens wearers. Mean time to diagnosis was 41 +/- 49 days (range 0-181 days, median 21 days). Fourteen patients (56%) had been treated with topical corticosteroids prior to the diagnosis. Early diagnosis of AK (<21 days) was associated with significantly better final visual acuity and did not require any surgical intervention compared with those diagnosed at a later stage. Six patients, all in the late diagnosis group, required surgical intervention.

CONCLUSIONS

AK has become significantly more common in New Zealand in the current decade. This study highlights the fundamental importance of early diagnosis and appropriate management in ensuring favourable outcomes. Practitioners should maintain a clinical suspicion of AK, especially as 96% of the subjects in this study were contact lens wearers.

Treatment with voriconazole in 3 eyes with resistant Acanthamoeba keratitis

PURPOSE

To report the use of topical voriconazole 1% (Vfend; Pfizer Inc, New York, New York, USA) ophthalmic solution for Acanthamoeba keratitis (AK) resistant to treatment with chlorhexidine (PerioChip; Dexel Pharma Technologies, Jerusalem, Israel).

DESIGN

Retrospective case series.

METHODS

Three eyes of 2 patients with culture-proven AK were treated at a tertiary care institution, and their charts were reviewed. Topical voriconazole 1% was instituted as second-line treatment for AK unresponsive to standard treatment with chlorhexidine and hexamidine. Treatment with voriconazole 1% was started at 1-hour intervals. Improvement was assessed and defined by absence of clinical signs of active infection and visual improvement.

RESULTS

One patient with unilateral AK and 1 patient with bilateral AK who remained culture-positive for Acanthamoeba despite ongoing treatment with chlorhexidine and hexamidine were treated with voriconazole 1% topical solution as an adjuvant. Both patients were contact lens wearers. Of 3 eyes additionally treated with voriconazole, 2 eyes had clinical resolution of disease. One eye demonstrated recurrent disease after penetrating keratoplasty that resolved after intrastromal injection of voriconazole.

CONCLUSIONS

We report the use of topical and intrastromal voriconazole in successfully treating AK in cases of chlorhexidine- and hexamidine-resistant Acanthamoeba. Voriconazole may be a promising adjuvant agent in treating AK.

Polymicrobial keratitis: Acanthamoeba and infectious crystalline keratopathy

PURPOSE

To report the early presentation, cause, and successful medical management of combined Acanthamoeba keratitis (AK) and infectious crystalline keratopathy (ICK).

DESIGN

Interventional case series.

METHODS

Retrospective review of 111 AK patients diagnosed and managed at the University of Illinois Eye and Ear Infirmary between June 1, 2003 and November 30, 2008 for an additional diagnosis of infectious keratitis.

RESULTS

Of 5 AK patients with microbiologic evidence of an additional bacterial keratitis during their active AK treatment, concomitant ICK developed in 3 patients. All patients were examined within 3 weeks of their AK diagnosis and were found to have characteristic signs and symptoms consistent with ICK. Bacterial culture results at the time of AK diagnosis were negative in 2 patients, but subsequent culture results were positive for Streptococcus oralis. Initial culture results demonstrated light growth of methicillin-sensitive Staphylococcus aureus in the remaining patient, who had received partial antibiotic treatment. Topical corticosteroids were used before diagnosis in 2 patients and were in use in only 1 patient after AK diagnosis. All infections resolved with medical therapy alone. One patient later required penetrating keratoplasty for visual rehabilitation.

CONCLUSIONS

In patients with AK, ICK can develop early and without either the use of corticosteroids or a preexisting epithelial defect, inconsistent with previously suggested mechanisms and major risk factors for secondary infection. Combined AK and ICK may exhibit increased pathogenicity with the onset of severe, often new, pain and acceleration of localized tissue loss and resultant scarring. Although early recognition and aggressive medical treatment were successful in resolving the combined infections in our cases, Acanthamoeba coinfection, and perhaps endosymbiosis, should be considered in the evaluation and clinical management of AK, especially in those cases progressing atypically. Further research is needed to understand the precise mechanism of the introduction of coinfectious pathogens and their role in the pathogenicity of AK.

Plant extracts as natural amoebicidal agents

Strains of Acanthamoeba sp. constitute a factor contributing to the occurrence of chronic granulomatous amoebic encephalitis, keratitis, pneumonia, as well as inflammations of other organs. Treatment of these diseases is very difficult and not always effective. A majority of these infections have been fatal. The aim of our study was to examine the amoebicidal or amoebistatic activity of plant extracts from Rubus chamaemorus, Pueraria lobata, Solidago virgaurea and Solidago graminifolia. For the purpose of isolation of pharmacologically active substances, we used the aboveground parts of plants, together with flowers, roots and leaves. It was established that extracts from S. virgauera, P. lobata and R. chamaemorus displayed chemotherapeutic properties in vitro in concentrations of approximately 0.01-0.05 mg extract/mL, i.e., in concentrations of 0.350 microg/mL expressed in ellagic acid for R. chamaemorus and 0.053 microg/mL expressed in puerarin for P. lobata. Therapeutic index values is 3.5-20. As a result of in vivo experiments, it was found out that, following therapy using the extracts, animals infected with Acanthamoeba sp. survived for an extended period (2.5-3 times longer). It was determined that plant extracts may be used both externally and internally in the case of a combined therapy for acanthamoebiasis. The tested extracts are not toxic for animals.

Glycogen phosphorylase in Acanthamoeba spp.: determining the role of the enzyme during the encystment process using RNA interference

Acanthamoeba infections are difficult to treat due to often late diagnosis and the lack of effective and specific therapeutic agents. The most important reason for unsuccessful therapy seems to be the existence of a double-wall cyst stage that is highly resistant to the available treatments, causing reinfections. The major components of the Acanthamoeba cyst wall are acid-resistant proteins and cellulose. The latter has been reported to be the major component of the inner cyst wall. It has been demonstrated previously that glycogen is the main source of free glucose for the synthesis of cellulose in Acanthamoeba, partly as glycogen levels fall during the encystment process. In other lower eukaryotes (e.g., Dictyostelium discoideum), glycogen phosphorylase has been reported to be the main tool used for glycogen breakdown in order to maintain the free glucose levels during the encystment process. Therefore, it was hypothesized that the regulation of the key processes involved in the Acanthamoeba encystment may be similar to the previously reported regulation mechanisms in other lower eukaryotes. The catalytic domain of the glycogen phosphorylase was silenced using RNA interference methods, and the effect of this phenomenon was assessed by light and electron microscopy analyses, calcofluor staining, expression zymogram assays, and Northern and Western blot analyses of both small interfering RNA-treated and control cells. The present report establishes the role of glycogen phosphorylase during the encystment process of Acanthamoeba. Moreover, the obtained results demonstrate that the enzyme is required for cyst wall assembly, mainly for the formation of the cell wall inner layer.

Factors affecting the epidemiology of Acanthamoeba keratitis

Despite being a relatively rare disease in comparison with other forms of infectious keratitis, Acanthamoeba keratitis is a potentially blinding disease. Wide variations in the incidence of Acanthamoeba keratitis have been reported in both developed and developing countries. At the same time that contact lens wear was found to be responsible for the spread of the disease in developed countries, Acanthamoeba keratitis was considered a rare disease in developing countries compared with fungal and bacterial keratitis. In recent decades, the risk of getting Acanthamoeba keratitis has increased because of the increased proportion of contact lens wearers. This article introduces the different factors affecting the epidemiology of Acanthamoeba keratitis worldwide, presents a chronological review of the literature, and shows the progressive spread of Acanthamoeba keratitis in the last two decades in different geographical areas of the world. A detailed comparison of the incidence of the disease as reported in different studies in different countries is made. The impact of contact lenses and other factors, such as hot weather, virulence of Acanthamoeba strains, water sanitation and quality, the occurrence of environmental disasters such as flooding, and the wide environmental presence of Acanthamoeba cysts on the incidence of the disease, are discussed. In addition, the ability of Acanthamoeba cysts to resist different harsh conditions is reviewed.

Acanthamoeba: biology and increasing importance in human health

Acanthamoeba is an opportunistic protozoan that is widely distributed in the environment and is well recognized to produce serious human infections, including a blinding keratitis and a fatal encephalitis. This review presents our current understanding of the burden of Acanthamoeba infections on human health, their pathogenesis and pathophysiology, and molecular mechanisms associated with the disease, as well as virulence traits of Acanthamoeba that may be targets for therapeutic interventions and/or the development of preventative measures.

Acanthamoeba keratitis: clinical characteristics and management

OBJECTIVE

To review the clinical characteristics, treatment, and outcome of patients with Acanthamoeba keratitis (AK).

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Twenty consecutive patients with AK were referred to the Beijing Tongren Hospital, Capital University of Medical Science, China.

METHODS

Retrospective analysis of medical records from 20 consecutive patients with AK between December 1, 1997 and March 30, 2003. Risk factors, laboratory investigations, clinical manifestations, treatments, and outcomes were analyzed.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) at the end of follow-up.

RESULTS

Of the 20 patients presented in this series, 12 patients were students and 6 were farmers. Risk factors included contact lens wear (12/20) and trauma (6/20). Corneal ulceration, diffuse stromal infiltration, and ring infiltration were the main clinical manifestations. The diagnosis of all patients was based on the laboratory investigation. Smear and culture positive specimens were 19 of 20 and 12 of 20, respectively. Images of cysts were demonstrated with confocal microscopy in 4 patients. Treatment was combined instillation of chlorhexidine (0.02%), neomycin (0.5%), metronidazole (0.4%), and/or lesion cauterization with chlorhexidine (1%), and corneal lesion debridement. The mean duration of therapy was 70 days (range, 18-150 days). Nineteen lesions healed with scar formation. The BCVA was better or equal to 20/100 in 7 eyes.

CONCLUSIONS

Early diagnosis of AK is the key challenge in clinical practice. The combined use of antiacanthamoeba agents, debridement, and cauterization may be a best choice of treatment for patients who are diagnosed early in the course of their disease.

In vitro evaluation of the effectiveness of the macrolide rokitamycin and chlorpromazine against Acanthamoeba castellanii

The present study demonstrates the in vitro effectiveness of the macrolide rokitamycin and the phenothiazine compound chlorpromazine against Acanthamoeba castellanii. Growth curve evaluations revealed that both drugs inhibit trophozoite growth in dose- and time-dependent ways. The effects of both drugs when they were used at the MICs at which 100% of isolates are inhibited were amoebistatic, but at higher doses they were amoebicidal as well as cysticidal. Experiments showed that when rokitamycin was associated with chlorpromazine or amphotericin B, rokitamycin enhanced their activities. Furthermore, low doses of rokitamycin and chlorpromazine, alone or in combination, blocked the cytopathic effect of A. castellanii against WKD cells derived from the human cornea. These results may have important significance in the development of new anti-Acanthamoeba compounds.

Persistently culture positive acanthamoeba keratitis: in vivo resistance and in vitro sensitivity

PURPOSE

To characterize the risk factors, clinical course, treatment outcome and the association between in vivo resistance and in vitro sensitivity for subjects with persistently culture-positive Acanthamoeba keratitis.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Eleven subjects with repeatedly positive cultures for Acanthamoeba treated between January 1990 and December 2000, were reviewed. Only subjects with 2 or more positive cultures, availability of the clinical data, and availability of the last Acanthamoeba isolate were included in this study.

METHODS

The medical records were analyzed, and the last isolate from each case was tested in vitro for the antiamoebic drugs used clinically: polyhexamethylene biguanide (PHMB), chlorhexidine, propamidine and hexamidine.

MAIN OUTCOME MEASURES

Risk factors, the clinical outcome and in vitro cysticidal drug sensitivity assay.

RESULTS

Eleven subjects (11/180, 6.1%) had 2 or more positive cultures of whom 8 eyes of 8 subjects (8/180, 4.45%) were included in this study. Seven of eight (87%) subjects were diagnosed over 1 month from onset (late diagnosis). The most common presenting findings were diffuse stromal infiltrate (5/8, 62.5%), ring infiltrate (5/8, 62.5%), and corneal ulceration (3/8, 37.5%). The clinical course of the disease in all subjects consisted of recurrent episodes of corneal and scleral inflammation, with a mean duration of 13.4 +/- 9 months. All subjects received PHMB, and 5/8 (62.5%) chlorhexidine too; hexamidine was used in combination in 6/8 (75%), and propamidine in 1/8 (12.5%). All subjects had topical steroids, and 5/8 (62.5%) systemic immunosuppression. The disease resolved with corneal scarring in 3/8 (37.5%) subjects, corneal (or impending) perforation treated with therapeutic keratoplasty in 4/8 (50%), and enucleation in 1/8 (12.5%). Final visual acuity was 0.43 +/- 0.37. In vitro most isolates were resistant to propamidine, hexamidine was cysticidal in high concentrations, and PHMB and chlorhexidine had excellent sensitivity profiles.

CONCLUSIONS

In our large series of Acanthamoeba keratitis with a positive microbiologic diagnosis at presentation, nearly 5% developed recurrent episodes of corneal and scleral inflammation with viable Acanthamoeba in the cornea despite prolonged treatment with biguanides and/or diamidines. There was no correlation between in vitro drug sensitivities and the in vivo response for biguanides.

Pathogenesis of Acanthamoeba infections

Acanthamoeba are free-living, harmless organisms, however, given the opportunity and the appropriate conditions, they can cause painful, sight-threatening as well as fatal infections and, thus, are considered opportunistic pathogens. Acanthamoeba infections have become increasingly important in the past few years due to increasing populations of contact lens users and AIDS patients. The mechanisms associated with the pathogenesis of Acanthamoeba tend to be highly complex, depending on parasite, host and the environmental factors. Elucidation of the biochemical, cellular and molecular basis of the pathogenesis of diseases caused by Acanthamoeba may lead to the development of therapeutic interventions.

Acanthamoeba spp. as agents of disease in humans

Acanthamoeba spp. are free-living amebae that inhabit a variety of air, soil, and water environments. However, these amebae can also act as opportunistic as well as nonopportunistic pathogens. They are the causative agents of granulomatous amebic encephalitis and amebic keratitis and have been associated with cutaneous lesions and sinusitis. Immuno compromised individuals, including AIDS patients, are particularly susceptible to infections with Acanthamoeba. The immune defense mechanisms that operate against Acanthamoeba have not been well characterized, but it has been proposed that both innate and acquired immunity play a role. The ameba's life cycle includes an active feeding trophozoite stage and a dormant cyst stage. Trophozoites feed on bacteria, yeast, and algae. However, both trophozoites and cysts can retain viable bacteria and may serve as reservoirs for bacteria with human pathogenic potential. Diagnosis of infection includes direct microscopy of wet mounts of cerebrospinal fluid or stained smears of cerebrospinal fluid sediment, light or electron microscopy of tissues, in vitro cultivation of Acanthamoeba, and histological assessment of frozen or paraffin-embedded sections of brain or cutaneous lesion biopsy material. Immunocytochemistry, chemifluorescent dye staining, PCR, and analysis of DNA sequence variation also have been employed for laboratory diagnosis. Treatment of Acanthamoeba infections has met with mixed results. However, chlorhexidine gluconate, alone or in combination with propamidene isethionate, is effective in some patients. Furthermore, effective treatment is complicated since patients may present with underlying disease and Acanthamoeba infection may not be recognized. Since an increase in the number of cases of Acanthamoeba infections has occurred worldwide, these protozoa have become increasingly important as agents of human disease.

Activities of therapeutic agents and myristamidopropyl dimethylamine against Acanthamoeba isolates

The activities of therapeutic agents and myristamidopropyl dimethylamine (MAPD) against Acanthamoeba strains recalcitrant to medical therapy were studied. MAPD minimum cysticidal concentrations were 6.25 to 25 microg/ml; 10 to 30 microg/ml gave at least a 3-log cyst kill after 6 h, and 50 and 100 microg/ml gave at least a 3-log cyst kill within 2 and 1 h, respectively.