Prevalence of acute conjunctivitis caused by chlamydia, adenovirus, and herpes simplex virus in an ophthalmic casualty department

Predictive Accuracy and Densitometric Analysis of Point-of-Care Immunoassay for Adenoviral Conjunctivitis

Purpose

Accurate diagnosis of adenoviral conjunctivitis (Ad-Cs) is important for timely and appropriate patient management to reduce disease transmission. This study assessed the diagnostic accuracy of a commercially available point-of-care adenovirus immunoassay and determined whether its predictive accuracy is influenced by signal intensities of test result bands.

Methods

Point-of-care immunoassay (AdenoPlus) testing and quantitative polymerase chain reaction (qPCR) testing was performed on conjunctival swab samples obtained from eyes of 186 eligible adult participants with presumed infectious conjunctivitis and symptoms of ≤4 days. Masked observers assessed signal intensities of the immunoassay test and control bands using densitometry.

Results

Ad-Cs was confirmed by qPCR in 28 of the 56 eyes that tested positive on the AdenoPlus, a 50% positive predictive value (95% confidence interval [CI] = 36.9, 63.1). No adenovirus was detected by qPCR in 128 of 130 eyes that tested negative on AdenoPlus, a 98.5% negative predictive value (CI = 96.3, 100). Sensitivity and specificity were 93% (CI = 84.4, 100) and 82% (CI = 76.0, 88.1), respectively. Viral titers significantly correlated with ratio of test band signal intensities (R² = 0.32, P = 0.002). Higher positive predictive value was associated with higher densitometry ratios (receiver operating characteristic [ROC] area = 0.71; 95% CI = 0.59, 0.83).

Conclusions

Densitometric analyses suggest that the diagnostic accuracy of AdenoPlus is influenced by the signal intensity of the test result bands. Visual comparison of the test band intensities by clinicians could reduce the false positive rate of point-of-care immunoassays and aid in the diagnosis of viral infections.

Translational Relevance

Ratiometric densitometry of point-of-care immunoassays could aid clinicians’ decision making in diagnosing infectious diseases, including Ad-Cs.

Epidemic keratoconjunctivitis in India: electronic medical records-driven big data analytics report IV

AIMS

To describe the clinical profile of epidemic keratoconjunctivitis (EKC) in patients presenting to a multitier ophthalmology hospital network in India.

METHODS

This retrospective hospital-based study included 2 408 819 patients presenting between August 2010 and February 2020. Patients with a clinical diagnosis of EKC in at least one eye with a recent onset (≤1 week) were included as cases. The data were collected using the eyeSmart electronic medical record system.

RESULTS

Overall, 21 196 (0.9%) new patients were diagnosed with EKC, of which 19 203 (90.6%) patients reported a recent onset (≤1 week) and were included for analysis. The median age was 32 (IQR: 22-45) years and adults (84.5%) were commonly affected. Most of the patients were male (62.1%) and unilateral (53.4%) affliction was commoner. The most common presenting symptom was redness (63.7%), followed by watering (42.1%). Preauricular lymphadenopathy or tenderness was documented in 1406 (7.3%) cases at presentation. A minority of the eyes had visual impairment worse than 20/200 (7.8%) due to associated ocular comorbidities. The involvement of the cornea was seen in 7338 (38.2%) patients and corneal signs included subepithelial infiltrates (26.3%), epithelial defect (1.4%), corneal oedema (0.9%) and filaments (0.4%). Of the patients who had corneal involvement, 496 (2.6%) patients had a chronic course beyond 1 month of which 105 (0.5%) had a course beyond 1 year.

CONCLUSION

EKC is a self-limiting condition that is commonly unilateral and predominantly affects males. About one-third of the patients have corneal involvement which rarely has a chronic course.

A generalized dose-response relationship for adenovirus infection and illness by exposure pathway

Adenoviruses are found everywhere in the environment, and cause various health problems including symptoms of enteric illness, and respiratory illness. Despite their significance to public health, few studies have addressed the health risks associated with exposure to adenovirus. Human challenge studies have been published for a few adenoviruses, which involved exposure through oral ingestion, inhalation, intranasal and intraocular droplet inoculation. Nothwithstanding the different symptoms resulting from such exposures, infection can be defined as colonization of a corresponding mucosa. A two-level dose-response model was developed to describe the distributions of infectivity and pathogenicity in various challenge studies of adenovirus, incorporating differences in inoculation route as shift in average infectivity and pathogenicity. This dose-response model can be used to make predictions for the infectivity of adenovirus, specific to any of the four studied inoculation methods. The generalized adenovirus dose-response relationship for infection and acute illness takes into account variation in infectivity and/or pathogenicity across adenovirus types, as well as uncertainty due to limited data.

Bacterial conjunctivitis

INTRODUCTION

Most cases of conjunctivitis in adults are probably due to viral infection, but children are more likely to develop bacterial conjunctivitis than they are viral forms. The main bacterial pathogens are Haemophilus influenzae and Streptococcus pneumoniae in adults and children, and Moraxella catarrhalis in children. Contact lens wearers may be more likely to develop gram-negative infections. Bacterial keratitis occurs in up to 30 per 100,000 contact lens wearers.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of empirical treatment in adults and children with suspected bacterial conjunctivitis? What are the effects of treatment in adults and children with bacteriologically confirmed bacterial conjunctivitis? What are the effects of treatment in adults and children with clinically confirmed gonococcal conjunctivitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 44 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: ocular decongestants, oral antibiotics, parenteral antibiotics, saline, topical antibiotics, and warm compresses.

Bacterial conjunctivitis

INTRODUCTION

Most cases of conjunctivitis in adults are probably due to viral infection, but children are more likely to develop bacterial conjunctivitis than they are viral forms. The main bacterial pathogens are Haemophilus influenzae and Streptococcus pneumoniae in adults and children, and Moraxella catarrhalis in children. Contact lens wearers may be more likely to develop gram-negative infections. Bacterial keratitis occurs in up to 30 per 100,000 contact lens wearers.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of empirical treatment in adults and children with suspected bacterial conjunctivitis? What are the effects of treatment in adults and children with bacteriologically confirmed bacterial conjunctivitis? What are the effects of treatment in adults and children with clinically confirmed gonococcal conjunctivitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 40 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: ocular decongestants; oral antibiotics; parenteral antibiotics; saline; topical antibiotics; and warm compresses.

Primary conjunctival herpetic geographic ulcer in an immunocompetent patient

Herpes simplex virus ocular infections have been recognized as a major cause of corneal blindness in the developed world. The major signs of a primary infection are limited to the lids, conjunctiva, and cornea. Presence of a conjunctival dendrite without corneal involvement has been reported. Although conjunctival ulceration has been associated with recurrent attacks, it has not been documented as a manifestation of primary herpetic infection. We report a case of primary herpetic infection with geographic conjunctival ulcer with multiple corneal dendrites.

Primary conjunctival herpetic geographic ulcer in an immunocompetent patient

Herpes simplex virus ocular infections are a major cause of corneal blindness in the developed world. Signs of a primary infection are limited to the lids, conjunctiva and cornea. The presence of a conjunctival dendrite without corneal involvement has been reported. Although conjunctival ulceration has been associated with recurrent attacks, it has not been documented as a manifestation of primary herpetic infection. We report a case of primary herpetic infection with geographic conjunctival ulcer with multiple corneal dendrites.

Herpes simplex virus epidemiology and ocular importance

PURPOSE

To review the changing epidemiology of herpes simplex disease and correlate it with the epidemiology of ocular herpes simplex disease.

METHOD

A review of pertinent reports in the world literature about the epidemiology of herpes simplex and specifically about ocular herpes simplex.

RESULTS

In developed countries, many individuals are reaching adolescence and adulthood without prior herpesvirus infection. Herpes simplex genital infection is increasing at a rapid rate in sexually active adolescents and adults, with about one in six adults now infected in the United States. Similar statistics are confirmatory worldwide in developed countries. Active herpes simplex infection is a risk factor for acquisition of human immunodeficiency virus. The Herpetic Eye Disease Study, as well as prior studies from Moorfields Eye Hospital and the Mayo Clinic in Rochester, Minnesota, provides us with the epidemiology of ocular herpes simplex. Recent studies suggest an older age of onset and perhaps overall more severe ocular disease as compared with the older literature.

CONCLUSIONS

Herpes simplex is a significant health concern at present with genital infections increasing in epidemic proportions. This is also reflected in a rise in the incidence of neonatal herpes. Herpes simplex virus type 1 (HSV-1) infection is being acquired for the first time in an older age group. A significant and increasing proportion of genital herpes is caused by HSV-1. Serologic studies are no longer as useful in distinguishing orofacial herpes from genital herpes. More acute retinal necrosis syndrome cases are associated with HSV-2. Speculation about the future of ocular herpes is made based on this changing epidemiology.

Causes of conjunctivitis and keratoconjunctivitis in Karachi, Pakistan

The causes of 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 (1.8%) 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 eyes in this study were resistant to antibiotics, probably because of inadequate and/or inappropriate self-medication with antibiotics in this community.

An immune dot-blot test for the diagnosis of ocular infection with Chlamydia trachomatis

We report a new simple non culture technique for the diagnosis of chlamydial eye disease. The immune dot-blot test (IDBT) detects chlamydial lipopolysaccharide (LPS) antigen which, after being trapped on nitrocellulose membrane, is detected by autoradiography with 125I-labelled genus specific monoclonal antibody. This test was evaluated over a two year period in adults and neonates, by comparing it to culture, serological detection of chlamydial antibodies and clinical features. We demonstrate that the IDBT is more than twice as sensitive as culture, and suggest that in order to achieve a reliable diagnosis of chlamydial eye infection an immunological test for chlamydial antigen should be used in preference to tests which detect the organisms themselves.

Per-nasal swabbing as an aid to the diagnosis of chlamydial and adenovirus conjunctivitis

Two hundred and thirty four patients (adults and babies) with conjunctivitis were investigated by taking eye swabs and in addition by taking per-nasal swabs. Chlamydia trachomatis was isolated from 20 patients and adenovirus from 14 patients. Per-nasal swabbing led to a 53% increase in chlamydia diagnosis and a 27% increase in the diagnosis of adenovirus infection. It is suggested that per-nasal swabbing has an important role to play in detecting chlamydial conjunctivitis which itself may be an indicator for high morbidity in patients and their contacts.

Epidemiology and diagnosis of acute conjunctivitis at an inner-city hospital

Chlamydia has been found to be the cause of a high percentage of cases of neonatal and chronic conjunctivitis in an inner-city population. To assess the etiology and epidemiology of acute conjunctivitis in this population, conjunctival scrapings were sampled from 45 patients presenting to an ocular emergency room; and replicate chlamydial, viral, and bacterial cultures and cytology tests were done. No cases of chlamydial conjunctivitis were diagnosed, although a viral etiology was established in 36% of the cases and a bacterial etiology in 40%. Twenty-four percent of the cases were not diagnosed. The authors recommend limiting the initial laboratory workup of patients with acute conjunctivitis to obtaining conjunctival smears for Gram and Giemsa staining. Chlamydial direct immunofluorescent monoclonal antibody (DFA) should be done if the patient is sexually active. Hyperacute conjunctivitis or acute conjunctivitis refractory to treatment mandates a more complete set of laboratory tests.

Management and prevention of ocular viral and chlamydial infections

A majority of cases of preventable and/or curable ocular morbidity and blindness are caused by ocular infections. They may account for 70 to 90% of all ocular morbidity seen by family doctors, general practitioners, health centers, and local ophthalmologists in both developed and developing countries. Unfortunately, most health authorities and doctors, including ophthalmologists, consider these diseases to be of little or no importance because they are not fully aware of the high prevalence of these infections and the blinding sequelae which may occur following incorrect diagnosis and treatment. Also, they are not aware of the social and economic impact of these infections in the absence of proper management and implementation of preventive measures. In this review, we examine present knowledge of chlamydial and common viral ocular infections. We discuss the problems of diagnosis, management, and prevention and propose solutions relevant to developed and developing countries.

Incidence and clinical presentation of chlamydial keratoconjunctivitis: a preliminary study

Using a direct immunofluorescent technique and monoclonal antibody, chlamydia trachomatis was detected in the conjunctival smears of 13 out of 47 patients presenting with conjunctivitis or keratoconjunctivitis (an incidence of 28%). Two patients presented with acute symptoms of few days duration, whereas the condition was chronic and of long duration in 11 patients. Conjunctival changes noted were upper and lower palpebral conjunctival follicles and papillae (11 patients), chemosis (5 patients), upper tarsal scar (2 patients) and pseudomembrane (one patient). Corneal involvement was detected in 9 patients and was manifested as micropannus (6 patients), multiple small epithelial punctate stains (3 patients), extensive pannus affecting the upper third of the cornea (2 patients), subepithelial punctate infiltrates similar to that of adenovirus infection (2 patients) and upper limbal follicles (one patient). Identification of chlamydia trachomatis in conjunctival smears by use of the monoclonal antibody is a simple, rapid and reliable laboratory procedure.

Evaluation of a commercial monoclonal antibody for detection of adenovirus antigen

The Adenoclone monoclonal antibody for detection of adenovirus antigen was evaluated by enzyme immunoassay and a 72-h indirect fluorescent-antibody test in shell vials and compared with standard culture. The sensitivity and specificity of the Adenoclone test were both 100% with 114 cell culture isolates. With 310 direct clinical specimens, the Adenoclone enzyme immunoassay sensitivity varied from 14.3 to 66.6%, but the Adenoclone indirect fluorescent-antibody test sensitivity was 86.7%, with 100% specificity.

Value and cost effectiveness of double culture tests for diagnosis of ocular viral and chlamydial infections

Swabbings from the eyes of 4132 patients attending ophthalmic casualty and outpatients clinics were tested for chlamydiae, adenovirus, and herpes simplex virus. Laboratory isolation tests gave positive results for one of these three agents in 696 (16.8%) cases. When a positive isolation was obtained, only 341 (49%) agreed with the clinical diagnosis while 355 (51%) either had no definite diagnosis marked on the request card or had been clinically diagnosed incorrectly. Routine testing of ocular specimens for all likely organisms can enable the correct treatment to be started sooner than doing one test at each visit, thereby reducing the number of times the patient has to visit the clinic and the expenses involved.

Adult follicular conjunctivitis and neonatal ophthalmia in a Liverpool eye hospital, 1980-1984

In the five year period between 1980 and 1984, 2146 adults and 172 neonates suffering from acute conjunctivitis underwent laboratory investigation for Chlamydia trachomatis (CT), Adenoviruses (AV), Herpes Simplex Virus (HSV) and pathogenic bacteria. Epidemiology and clinical features are presented and discussed. CT was detected in 29 per cent of neonates with conjunctivitis. 5.6 per cent of adults and older children investigated for follicular conjunctivitis were CT positive. There was a significant female preponderance among CT positive neonates of 1.9:1 (p less than 0.02). 91 per cent of neonates and 62 per cent of adults in whom CT was detected were receiving some sort of treatment. Serotypes 7, 3, 10, 4 and 8 were responsible in decreasing order of frequency for 96 per cent of AV infections. Serotype 7 was seen for the first time in an adult age distribution. HSV was isolated in 1.3 per cent of cases in the absence of typical lid or corneal lesions. Viral infection was not detected in any neonate. Bacterial infection was a more likely cause than CT in neonates if infection had persisted longer than 5 weeks (p much less than 0.001). Neonates with Staph aureus infection tended to present earlier in the course of disease than those with Haemophilus sp or Pneumococcus (p less than 0.05).

Latent oculogenital infection with Chlamydia trachomatis

Thirty patients attending a sexually transmitted disease clinic were evaluated for genital and ocular infection with chlamydia. Eight patients had positive conjunctival immunofluorescent staining. This represents an asymptomatic, latent carrier state with important epidemiologic considerations.

Spontaneous resolution of herpes simplex blepharoconjunctivitis in children

We observed three children, aged 1 year 8 months to 9 years 7 months, in whom herpes simplex blepharoconjunctivitis resolved promptly without treatment. A fourth child, 8 years old, developed probable toxic manifestations from topical vidarabine. These manifestations, as well as the blepharoconjunctivitis, resolved when the medication was discontinued. Herpes simplex ocular infection without corneal involvement in children is usually benign and self-limited.

Rapid diagnosis of Chlamydia trachomatis infection in patients attending an ophthalmic casualty department

Direct immunofluorescence (DIF) techniques were compared with conventional cell culture for the diagnosis of ocular infections with Chlamydia trachomatis. The DIF test was found to have a sensitivity of 100% and a specificity of 97.5%. Of 178 patients studied, 19 patients (11%) were positive by DIF and 15 (8.4%) by conventional cell culture technique. Four patients who had previous treatment with chloramphenicol eye drops were negative by cell culture but positive by the DIF test. The DIF test is considered to be a rapid, accurate test with a number of advantages over culture techniques for the detection of C. trachomatis. The importance of appropriate referral of positive patients to prevent more serious sequelae due to C. trachomatis infection is discussed.

A microbiological study of conjunctivitis with emphasis on Chlamydia trachomatis, in northern Norway

To determine the microbiological agents in conjunctivitis in children and young adults, physicians outside hospitals were asked to obtain samples from the conjunctiva in patients presenting with conjunctivitis. Specimens from 194 patients and 177 healthy controls were cultivated for Chlamydia trachomatis. In 12 cases Chlamydia trachomatis was isolated (i.e. 4 neonates, 1 three-year-old child and 7 adults, aged 17 to 39 years), but in none of the controls. Of the specimens from patients 168 and all of the healthy controls were cultivated for both bacteria (including Chlamydia trachomatis) and viruses. The main micro-organisms, regarded as infectious, were Haemophilus influenzae (20), Streptococcus pneumoniae (18), Staphylococcus aureus (14) and Chlamydia trachomatis (9). Haemophilus influenzae (non-typable strains) were isolated more frequently in the age group below 5 years of age than in the age group 5-50 years. Herpes simplex virus (type II) was isolated in one neonate. Chlamydia trachomatis is among the most important infectious agents in conjunctivitis treated outside hospitals. As chlamydial infections need special attention regarding treatment and follow-up, physicians should be encouraged to obtain specimens for microbiological examination, including chlamydia, from the population at risk.

Tear and serum antibody levels in ocular herpetic infection: diagnostic precision of secretory IgA

A sensitive enzyme linked immunosorbent assay (ELISA) was developed to evaluate the potential of herpes simplex virus (HSV) specific antibodies in the diagnosis of herpetic eye infection. The presence of HSV specific secretory IgA (sIgA) in tears was found to be diagnostic of infection. However, serum and tear HSV specific IgG and IgA were not considered reliable indicators of active infection.

Recent advances in Chlamydia trachomatis

Chlamydia trachomatis is an obligate intracellular energy parasitic bacterium with a genome of 660 X 10(6) daltons, possessing a plasmid and unique life cycle which includes the differentiation of the infective elementary body to a replicative reticulate body. C. trachomatis is the etiological agent of trachoma, which affects approximately 500 million people in developing countries. Recently it became evident that in industrialised Western nations certain strains of C. trachomatis are the most common cause of sexually transmitted infections such as non-gonococcal urethritis, cervicitis, endometritis, salpingitis and subsequent ectopic pregnancies or infertility, perihepatitis, neonatal conjunctivitis and pneumonia, adult conjunctivitis and epididymitis. Since C. trachomatis infections are often asymptomatic, widespread screening of sexually active young people is needed in order to initiate early antibiotic treatment which may prevent serious complications such as ectopic pregnancies and infertility. Development of sensitive and simple techniques for mass screening for detection of Chlamydia in excretions as well as techniques for detection of specific markers of chronic internal infections (such as Chlamydia specific IgA antibodies) is of great importance.

Rapid, reliable diagnosis of chlamydial ophthalmia by means of monoclonal antibodies

The use of fluorescein-conjugated monoclonal antibody (Syva, UK) provided a rapid reliable diagnostic test for Chlamydia trachomatis in conjunctival samples from 100 adults with acute follicular conjunctivitis and seven babies with suspected chlamydial ophthalmia neonatorum. Elementary bodies (EBs) were seen in smears from 11 of the adults, and culture confirmed C. trachomatis infection in nine of them. Both tests were positive with specimens from four of the neonates. No specimens from either group of patients produced a negative result in the smear test but a positive result by culture. However, the two adult patients with chlamydial ophthalmia who had negative cultures but were EB-positive had both had prior topical tetracycline therapy.

Epidemiological and clinical features of primary herpes simplex virus ocular infection

The epidemiological and clinical features of primary herpes simplex virus ocular infection in 108 patients were studied. Of these, 69 (64%) were aged 15 or over and only eight (7%) were under the age of 5. Associated upper respiratory tract infection was found in 38 (35%) patients and systemic disorders such as mild malaise, fever, and aching in 34 (31%) patients. Common symptoms were redness, watering, discharge, itching, irritation, and lid swelling, whereas pain, photophobia, lid vesicles and ulcers, and blurred vision were less frequent. The major signs consisted of vesicles and ulcers on the lids, papillary responses which were more severe in the upper lid conjunctiva, follicles which were more common in the lower lid conjunctiva, fine and coarse epithelial punctate keratitis, and subepithelial punctate keratitis. Dendritic ulcers and disciform keratitis were found in 16 (15%) and two (2%) patients respectively. The clinical forms of primary herpes simplex virus ocular infection varied. Moderate or severe disease was observed in 41 (38%) and 16 (15%) patients respectively. In eight (7%) patients the disease presented as an acute follicular conjunctivitis without characteristic lid or corneal lesions. A chronic blepharoconjunctivitis which lasted for months developed in 16 (15%) patients. The epidemiological and clinical features in our patients were compared with features of the disease reported previously.