Acanthamoeba keratitis

Impact of implementation of polymerase chain reaction on diagnosis, treatment, and clinical course of Acanthamoeba keratitis

PURPOSE

Acanthamoeba keratitis (AK) is a painful and possibly sight-threatening ocular infection. While the correct diagnosis and specific treatment in the early stages significantly improve the prognosis, the disease is often misdiagnosed and in clinical examination confused with other forms of keratitis. Polymerase chain reaction (PCR) for the detection of AK was first introduced in our institution in December 2013 to improve the timely diagnosis of AK. The aim of this study was to assess the impact of implementation of Acanthamoeba PCR on the diagnosis and treatment of the disease in a German tertiary referral center.

PATIENTS AND METHODS

Patients treated for Acanthamoeba keratitis between 1st of January 1993 and 31st of December 2021 in the Department of Ophthalmology of the University Hospital Duesseldorf were identified retrospectively via in-house registries. Evaluated parameters include age, sex, initial diagnosis, method of correct diagnosis, duration of symptoms until correct diagnosis, contact lens use, visual acuity, and clinical findings as well as medical and surgical therapy by keratoplasty (pKP). In order to assess the impact of implementation of Acanthamoeba PCR, the cases were divided into two groups (before (pre-PCR group) and after PCR implementation (PCR group).

RESULTS

Seventy-five patients with Acanthamoeba keratitis were included (69.3% female, median age 37 years). Eighty-four percent (63/75) of all patients were contact lens wearers. Until PCR was available, 58 patients with Acanthamoeba keratitis were diagnosed either clinically (n = 28), by histology (n = 21), culture (n = 6), or confocal microscopy (n = 2) with a median duration until diagnosis of 68 (18; 109) days. After PCR implementation, in 17 patients, the diagnosis was established with PCR in 94% (n = 16) and median duration until diagnosis was significantly shorter with 15 (10; 30.5) days. A longer duration until correct diagnosis correlated with a worse initial visual acuity (p = 0.0019, r = 0.363). The number of pKP performed was significantly lower in the PCR group (5/17; 29.4%) than in the pre-PCR group (35/58; 60.3%) (p = 0.025).

CONCLUSIONS

The choice of diagnostic method and especially the application of PCR have a significant impact on the time to diagnosis and on the clinical findings at the time of confirmation of diagnosis and the need for penetrating keratoplasty. In contact lens-associated keratitis, the first crucial step is to take AK into consideration and perform a PCR test as timely confirmation of diagnosis of AK is imperative to prevent long-term ocular morbidity.

Acanthamoeba keratitis: an emerging disease gathering importance worldwide?

Acanthamoeba keratitis (AK) is increasingly being recognized as a severe sight-threatening ocular infection worldwide. Although contact lens wear is the leading risk factor for AK, Acanthamoeba parasites are also an important cause of keratitis in non-contact lens wearers. Diagnosis of AK is challenging, and the available treatments are lengthy and not fully effective against all strains. The pathogenesis of Acanthamoeba is still under study, and the identification of the key factors involved in this process should be useful for the development of fully effective therapies. This review focuses on recent developments on AK pathogenesis and diagnosis as well as novel strategies for the evaluation of anti-amoebic agents that could be applied in the near future against these pathogens.

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.

TLR4: the receptor bridging Acanthamoeba challenge and intracellular inflammatory responses in human corneal cell lines

Acanthamoeba keratitis (AK) is a painful, vision-threatening infection caused by pathogenic strains of the protozoan, Acanthamoeba. Toll-like receptors (TLRs), which are important components of innate immunity, have an important role in the detection of foreign pathogens and the signaling cascades in host cells. However, no report on the interaction between Acanthamoeba and TLR has been found. In this study we analyzed the role of the TLR and its signaling pathway in human telomerase-immortalized corneal epithelial cells (HUCLs) and stromal fibroblasts (THSFs) challenged by Acanthamoeba. We show that the expressions of TLR4, myeloid differentiation protein 88 (MyD88), nuclear factor (NF)-kappaB, phospho-IkappaB, phospho-extracellular signal-regulated kinases 1/2 (p-Erk1/2) and the inflammatory cytokines interleukin (IL)-8, tumor necrosis factor (TNF)-alpha and interferon (IFN)-beta were significantly increased in Acanthamoeba-treated cells. Pretreatment with anti-TLR antibodies or the specific inhibitors pyrrolidine dithiocarbamate (PDTC) (for the NF-kappaB pathway) and U0126 (for the ERK pathway) was conducted. It was found that anti-TLR4 antibody attenuated the production of cytokines induced by Acanthamoeba infection. PDTC inhibited the production of IL-8 and TNF-alpha whereas U0126 inhibited the synthesis of IFN-beta. Thus, TLR4 is a receptor for Acanthamoeba and exerts an effect through TLR4-MyD88-NF-kappaB and TLR4-ERK1/2 pathways to induce the secretion of cytokines in human corneal cell lines challenged by Acanthamoeba.

Evaluation of three different methods to establish animal models of Acanthamoeba keratitis

PURPOSE

To produce animal models of Acanthamoeba keratitis and to evaluate the advantages and adaptation range of each of the three methods employed.

MATERIALS AND METHODS

Mice and Wistar rats in three groups of 15 rats and 15 mice each were used to establish the models. Right corneas in group A were scratched and challenged with Acanthamoeba. Those in group B were scratched and covered with contact lenses incubated with Acanthamoeba. Those in group C received an intrastromal injection of Acanthamoeba. Five rats and 5 mice in each group were used for histopathological investigations and the other 10 in each group were used for clinical evaluation. The models were evaluated by slit lamp examination, microscopic examination and culture of corneal scrapings, HE staining of corneal sections, and pathological scoring of the infections.

RESULTS

Four rats and 6 mice in group A, 7 rats and 8 mice in group B, and 10 rats and 10 mice in group C developed typical Acanthamoeba keratitis.

CONCLUSION

Corneal scratching alone has the lowest infection rate, while scratching and then covering with contaminated contact lenses has a moderate rate of infection and most closely mimics what happens in most human infections. Intrastromal injection of Acanthamoeba gives a much higher infection rate and more severe Acanthamoeba keratitis.

Temporal and seasonal trends in Acanthamoeba keratitis

PURPOSE

The purpose of this study was to assess the incidence and risk factors of Acanthamoeba keratitis (AK) over an 8-year period in a Canadian tertiary care setting.

METHODS

We retrospectively reviewed the medical records of 41 patients (42 eyes), who were diagnosed as having AK between January 1999 and December 2006 in the cornea clinic at the Toronto Western Hospital. The incidence and risk factors of AK were evaluated.

RESULTS

The number of cases per year increased from between 0 and 4 in the first 5 years to 9, 14, and 8 in the last 3 years. The annual increasing trend was statistically significant (P = 0.04). The month of onset of disease symptoms showed a trend toward onset in summer and fall and was statistically significant for the difference between January and August (P = 0.0094). The season of onset of disease symptoms showed a trend toward summer onset, and the difference between winter and summer was statistically significant (P = 0.02). 92.9% of cases occurred in contact lens wearers, particularly in soft contact lens wearers (82.1%).

CONCLUSIONS

The incidence of AK in Canada may be increasing since 2004. There is a seasonal trend toward disease onset in the warmer months.

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.

The epidemiology of contact lens related infiltrates

With estimated numbers of contact lens wearers worldwide exceeding 140 million, even complications with a low incidence will affect a significant number of individuals. Although contact lenses clearly have many advantages for wearers, certain risks have been associated with their use. Differences in risk for different types of contact lenses and wearing patterns have been demonstrated for both rare and common lens related complications. This review particularly focuses on the incidence and etiology of contact lens related corneal infection and inflammation. An understanding of the risks and contributory factors to these conditions is important for practitioners and will enable an informed choice of safer lens wear modalities, wear schedules, and hygiene regimes to be made.

[Keratitis due to Acanthamoeba]

Free-living amebae appertaining to the genus Acanthamoeba, Naegleria and Balamuthia are the most prevalent protozoa found in the environment. These amebae have a cosmopolitan distribution in soil, air and water, providing multiple opportunities for contacts with humans and animals, although they only occasionally cause disease. Acanthamoeba spp. are the causative agent of granulomatous amebic encephalitis, a rare and often fatal disease of the central nervous system, and amebic keratitis, a painful disease of the eyes. Keratitis usually follows a chronic course due to the delay in diagnosis and subsequent treatment. The clear increase in Acanthamoeba keratitis in the last 20 years is related to the use and deficient maintenance of contact lenses, and to swimming while wearing them. The expected incidence is one case per 30,000 contact lens wearers per year, with 88% of cases occurring in persons wearing hydrogel lenses. This review presents information on the morphology, life-cycle and epidemiology of Acanthamoeba, as well as on diagnostic procedures (culture), appropriate antimicrobial therapy, and prevention measures.

Acanthamoeba isolates belonging to T1, T2, T3, T4 and T7 genotypes from environmental freshwater samples in the Nile Delta region, Egypt

The free-living amoebae of the genus Acanthamoeba include non-pathogenic and pathogenic species and has been recently classified into 15 different genotypes, T1-T15. In this study, a survey was conducted in order to determine the presence and pathogenic potential of free-living amoebae of Acanthamoeba genus in freshwater sources associated with human activities in the Nile Delta region, Egypt. Identification of Acanthamoeba was based on the morphology of cyst and trophozoite forms and PCR amplification with a genus specific primer pair. The pathogenic potential of Acanthamoeba isolates was characterized using temperature and osmotolerance assays and PCR reactions with two primer pairs specific to Acanthamoeba pathogenesis. Isolates genotypes were also determined after ribosomal DNA sequencing. These data revealed that isolates belong to T1, T2, T3, T4 and T7 genotypes. As expected, T4 isolates exhibited the most pathogenic traits and were osmotolerant, temperature tolerant and expressed extracellular serine proteases. This is the first report presenting environmental distribution of Acanthamoeba genotypes in Egypt.

Acanthamoeba Keratitis and Contact Lens Disinfecting Solutions

OBJECTIVES

To report cases of culture-proved Acanthamoeba keratitis in Greece over a 10-year period and to evaluate the effectiveness of the commonly used commercial contact lens disinfecting systems in clinical cases of Acanthamoeba keratitis.

MATERIAL AND METHODS

During the years 1994-2004, 45 contact lens wearers and 3 non-contact lens wearers presenting with symptoms and signs of keratitis underwent corneal sampling. The scrapings obtained were inoculated directly onto appropriate culture media for bacteria, fungi and Acanthamoeba. All proved positive for Acanthamoeba. The contact lenses and contact lens disinfecting solutions (16 one-step 3% hydrogen peroxide and 3 multipurpose solutions) of 19/45 patients with culture-proven Acanthamoeba keratitis were cultured for bacteria, fungi and Acanthamoeba.

RESULTS

Acanthamoeba was isolated from contact lenses and contact lens disinfecting solutions in all 19 cases of Acanthamoeba keratitis studied.

CONCLUSIONS

The main risk factor for corneal infection in contact lens wearers is the use of contact lens disinfecting systems ineffective at killing Acanthamoeba cysts and trophozoites, as well as bacteria and fungi. Improvement or development of new contact lens disinfecting systems by manufacturers is needed to prevent Acanthamoeba keratitis.

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.

Attachment of Acanthamoeba to first- and second-generation silicone hydrogel contact lenses

PURPOSE

To investigate the attachment of Acanthamoeba to first- and second-generation silicone hydrogel contact lenses, and to determine if patient wear or the presence of a bacterial biofilm coating affects attachment characteristics.

DESIGN

Experimental study.

PARTICIPANTS AND CONTROLS

Attachment to the silicone hydrogel lenses was compared with that to a conventional hydrogel control lens. Sixteen replicates (n = 16) were carried out for unworn, worn, and biofilm-coated lenses of each type.

METHODS

Unworn, worn, and Pseudomonas aeruginosa biofilm-coated first-generation (lotrafilcon A) and second-generation (galyfilcon A) silicone hydrogel and conventional hydrogel (etafilcon A) lens quarters were incubated for 90 minutes in suspensions of plate-cultured Acanthamoeba castellanii trophozoites.

MAIN OUTCOME MEASURES

Trophozoites attached to one surface of each lens quarter were counted by direct light microscopy. Logarithmic transformation of data allowed the use of parametric analysis of variance for statistical analysis.

RESULTS

Attachment of Acanthamoeba was affected significantly by lens material type (P<0.001), with higher numbers of trophozoites attaching to the first-generation lotrafilcon A silicone hydrogel lens, compared with the second-generation galyfilcon A lens and the conventional hydrogel lens. Attachments to the latter 2 lenses did not differ significantly from each other (P = 0.126). Patient wear and the presence of a bacterial biofilm had no significant effect on attachment to the lotrafilcon A lens (P = 0.426) but did significantly increase attachment to the galyfilcon A (P<0.001) and the etafilcon A (P = 0.009) lenses; attachment to the latter 2 lenses was still significantly less than that found with the first-generation silicone hydrogel (P<0.001).

CONCLUSIONS

Acanthamoeba demonstrated a significantly greater affinity for the first-generation silicone hydrogel lens as compared with the second-generation silicone hydrogel and the conventional hydrogel. If exposed to Acanthamoeba (e.g., when showering or swimming, through noncontinuous wear and ineffective lens care regimes), first-generation silicone hydrogel lenses may promote a greater risk of Acanthamoeba infection due to the enhanced attachment characteristics of this lens material. However, prospective studies in patients are required to determine if these experimental results are clinically significant.

Isolation and identification of pathogenic Acanthamoeba strains in Tenerife, Canary Islands, Spain from water sources

A comprehensive survey to document the presence of free-living amoebae of the genus Acanthamoeba was conducted in tap water and sea water sources related to human environments in Tenerife, Canary Islands, Spain. Acanthamoeba identification was based on the morphology of cyst and trophozoite forms and PCR amplification with a genus-specific primer pair. The pathogenic potential of Acanthamoeba isolates was characterized by temperature and osmotolerance assays and PCR reactions with two primer pairs related to Acanthamoeba pathogenesis. The results demonstrate the presence of potentially pathogenic strains in both sources. Thus, some of the amoebae in these aquatic habitats can act as opportunistic pathogens, could play a role in the diseases of aquatic organisms, and may present a risk to human health.

Acanthamoeba keratitis update—incidence, molecular epidemiology and new drugs for treatment

A reliable figure for the expected incidence of Acanthamoeba keratitis of one per 30000 contact lens wearers per year has now been obtained from a combination of three cohort and three Questionnaire Reporting Surveys; 88% of cases wore hydrogel lenses and 12% wore rigid lenses. This figure now provides a basis for the expected number of cases against which to judge either epidemic outbreaks or effects of prevention with disinfecting solutions, better hygiene, or the use of disposable lenses. Molecular biology of Acanthamoeba has advanced considerably in the last 10 years with new automated sequencing technology. This has allowed the construction of a genotype identification scheme with 13 different genotypes against which to compare clinical isolates for epidemiological investigations or pathogenicity markers. So far, only four genotypes have been associated with keratitis of which the majority have been T4 but T3, T6, and T11 have each caused individual cases. Each genotype is heterogenous and can be further subdivided by comparison of sequences of diagnostic fragments of 18S rDNA, riboprinting by PCR-RFLP of 18S rDNA, or by mitochondrial DNA RFLP. Drug therapy has been revolutionised with the introduction of the biguanides-chlorhexidine or polyhexamethylene biguanide-with most but not all infections quickly resolving. Failure can still occur occasionally and further research is needed on more effective combination chemotherapy. A number of guanidines have been identified in this paper that could be usefully pursued as part of combination chemotherapy along with the alkylphosphocholines.