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Spena R, Bovone C, Ciarmatori N, Pellegrini M, Yu AC, Zauli G, Busin M. Microsporidial Stromal Keratitis in Post-Keratoplasty Eyes. J Clin Med 2023; 12:jcm12113706. [PMID: 37297901 DOI: 10.3390/jcm12113706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
PURPOSE The purpose of this paper is to report the clinical manifestations, diagnostic evaluation, management and outcomes of microsporidial keratitis in post-keratoplasty eyes. METHODS This is a retrospective review of three patients diagnosed with microsporidial stromal keratitis in post-keratoplasty eyes between January 2012 and December 2021 at a tertiary referral center (Ospedali Privati Forlì "Villa Igea", Forlì, Italy). RESULTS All patients presented with fine multifocal granular infiltrates following keratoplasty for a presumed herpetic keratitis. No microorganisms were isolated from the corneal scrapings and no clinical response was observed with broad-spectrum antimicrobial therapy. In all cases, confocal microscopy demonstrated spore-like structures. The histopathologic examination of the excised corneal buttons confirmed the diagnosis of microsporidial stromal keratitis. Following therapeutic keratoplasty and treatment with an initial high dose and extended taper of topical fumagillin, clinical resolution was achieved in all eyes. The Snellen visual acuities at the final follow-up were 20/50, 20/63 and 20/32. CONCLUSIONS Prior to definitive surgery, confocal microscopy can be employed for the in vivo detection of pathogenic microorganisms such as Microsporidium. In post-keratoplasty eyes, therapeutic keratoplasty and an initial high dose of topical fumagillin with extended taper can allow the resolution of microsporidial stromal keratitis with a satisfactory visual prognosis.
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Affiliation(s)
- Rossella Spena
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| | - Cristina Bovone
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
- Department of Environmental Sciences and Prevention, University of Ferrara, 44122 Ferrara, Italy
| | - Nicolò Ciarmatori
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| | - Marco Pellegrini
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| | - Angeli Christy Yu
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| | - Giorgio Zauli
- Research Department, King Khaled Eye Specialist Hospital, Riyadh 11462, Saudi Arabia
| | - Massimo Busin
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
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Mohanty A, Sahu SK, Sharma S, Mittal R, Behera HS, Das S, Lakhmipathy M. Past, present, and prospects in microsporidial keratoconjunctivitis- A review. Ocul Surf 2023; 28:364-377. [PMID: 34419638 DOI: 10.1016/j.jtos.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/19/2021] [Accepted: 08/14/2021] [Indexed: 11/29/2022]
Abstract
Ocular microsporidiosis comprises two entirely different spectra of disease as keratoconjunctivitis and stromal keratitis. Microsporidial keratoconjunctivitis (MKC) has been increasingly reported in the past two decades, probably due to raised awareness, simpler diagnostic procedures, and a better understanding of the clinical presentation. It is characterized by the presence of raised, coarse, punctate, multifocal, round to oval, greyish-white corneal epithelial lesions which usually evolve into nummular scars before resolution. Conjunctivitis seen is non-purulent and of mild-moderate intensity, with mixed papillary-follicular reaction. The mode of transmission and pathogenesis is poorly understood. Despite lack of inflammatory response, uncommon associations reported were- endotheliitis, corneal edema, limbitis, uveitis, and sub-epithelial infiltrates. There has been no consensus on the management of MKC. It varies from the use of multiple antimicrobial agents to simple lubricants. The majority of the disease goes underdiagnosed or misdiagnosed and treated as adenoviral keratoconjunctivitis, with topical steroids or anti-virals empirically. Changing trends have been noticed in the pattern of infection, possibly with increasing evidence of Vittaforma corneae as causative organisms, previously reported to cause stromal keratitis. An elaborate review of the past and present literature on MKC is provided in this review article, along with gaps in knowledge, and future directions of research.
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Affiliation(s)
- Amrita Mohanty
- Cornea and Anterior Segment Services, L. V. Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar, Odisha, India
| | - Srikant K Sahu
- Cornea and Anterior Segment Services, L. V. Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar, Odisha, India.
| | - Savitri Sharma
- Jhaveri Microbiology Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India
| | - Ruchi Mittal
- Kanupriya Dalmia Ophthalmic Pathology Laboratory, L.V. Prasad Eye Institute, Bhubaneswar, Odisha, India; Department of Pathology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Himansu Sekhar Behera
- Ocular Microbiology Service, L.V. Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar, Odisha, India
| | - Sujata Das
- Cornea and Anterior Segment Services, L. V. Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar, Odisha, India
| | - Meena Lakhmipathy
- Department of Cornea and Refractive Surgery, Medical Research Foundation, Sankara Nethralaya, Chennai, India
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Dhiman R, Agarwal S, Anand AR, Lakshmipathy D, Srinivasan B, Iyer G. Coexistence of Fungal Keratitis in Bilateral Sequential Microsporidial Keratitis - A Rare Case Presentation. Ocul Immunol Inflamm 2022; 30:2062-2064. [PMID: 34464229 DOI: 10.1080/09273948.2021.1969412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM To report a case of bilateral microsporidiosis with coexisting fungal infection in one eye. METHOD Retrospective interventional case report. RESULTS A 61-year-old man with uncontrolled diabetes presented with clinical and microbiological features of non-resolving fungal keratitis in the right eye since 3 months and underwent therapeutic penetrating keratoplasty (TPK) for the same. Fungal filaments along with oval bodies suspicious of microconidia were noted on calcofluor stain. A week following TPK, the patient presented with features of viral keratouveitis in the left eye which on microbiology was confirmed as microsporidiosis. Retrospectively, the right eye microbiology slides were reassessed, which confirmed the coexistence of fungus with microsporidiosis by acid-fast stain and polymerase chain reaction. CONCLUSION Structural resemblance of microconidia with microsporidial spores can be misleading, thus creating a need for awareness regarding the possible coexistence along with a need to suspect microsporidiosis in nonresponding clinically resembling viral keratitis.
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Affiliation(s)
- Richa Dhiman
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Shweta Agarwal
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Appakkudal R Anand
- L&T Microbiology Research Centre, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | | | - Bhaskar Srinivasan
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Geetha Iyer
- Dr G Sitalakshmi Memorial Clinic for Ocular Surface Disorders, CJ Shah Cornea Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
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Matoba A, Goosey J, Chévez-Barrios P. Microsporidial Stromal Keratitis: Epidemiological Features, Slit-Lamp Biomicroscopic Characteristics, and Therapy. Cornea 2021; 40:1532-1540. [PMID: 33782266 DOI: 10.1097/ico.0000000000002704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/18/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Microsporidial stromal keratitis is a rare form of infectious keratitis, with only 7 cases reported in the United States to date. This study was performed to evaluate risk factors, clinical features, and response to therapy. METHODS A retrospective review of the medical records of all patients diagnosed with microsporidial stromal keratitis seen in the practices of the authors between 1999 and 2020 was performed. Diagnosis was determined by cytology or histopathology in corneal specimens. Risk factors, presence or absence of distinctive clinical features, and response to medical and surgical therapies were recorded. RESULTS Nine patients-7M:2F, aged 7 to 99 years-with microsporidial stromal keratitis were identified. Exposures to recreational water and hymenopteran insect bites, both epidemiologically linked risk factors for systemic microsporidial infection, were identified in our patients. Presence of stromal edema with features of disciform keratitis and a distinctive granular keratitis were observed in 6 of 9 and 5 of 9 patients, respectively. Poor response to medical therapy was noted. Penetrating keratoplasty was effective in curing the infection. Final visual acuity was 20/40 or better in 6 of 9 patients. CONCLUSIONS In patients with slowly progressive keratitis, history of exposure to recreational water or hymenopteran insects should be sought. In patients with corneal edema consistent with disciform keratitis, with evolution to a granular keratitis, microsporidia should be considered in the differential diagnosis. In cases of established microsporidial stromal keratitis, penetrating keratoplasty should be considered if prompt response to medical therapy is not noted.
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Affiliation(s)
- Alice Matoba
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX
| | | | - Patricia Chévez-Barrios
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX; and
- Departments of Pathology and Laboratory Medicine, and Ophthalmology, Weill Medical College of Cornell University, New York City, NY
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Mittal R, Agarwal S, Muduli KC, Sahu S, Das S. Acid and heat fastness in microsporidia: How acid fast are acid fast microsporidium? Med Mycol 2021; 58:1010-1013. [PMID: 31965173 DOI: 10.1093/mmy/myz137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/27/2019] [Accepted: 12/24/2019] [Indexed: 11/14/2022] Open
Abstract
Microsporidia are obligate spore-forming microorganisms with strong resemblance to fungi and can affect almost every organ system in immunocompetent or immunocompromised individuals. Mixed infections are also reported in immunocompromised hosts. Microsporidial spores show marked morphological variations and the small and slender forms can resemble bacilli. Modified Zeihl Neelsen (ZN) stain, cold method demonstrates them as bright red in color, leaving several spores blue or incompletely stained; thus, they are reported as weakly or variably acid fast. Variability in staining results with ZN stain and considering the fact that Mycobacterium tuberculosis, the commoner bug in developing countries is identified by its resistance to stronger acids on ZN staining, authors wished to demonstrate acid and heat fastness in microsporidium using corneal tissue specimens. Microsporidial spores stained bright red in color with conventional ZN stain, demonstrated strong acid fastness, and interestingly the staining results improved on heating. Thus, the authors conclude that they are strongly acid and heat fast and care must be warranted so that they are not misdiagnosed as Mycobacterium or other acid-fast organisms. Careful observation of morphology, battery of special stains, and molecular diagnostics should be advocated for diagnostic confirmation. To the best of the authors' knowledge, this is the first explicit report on acid and heat fastness on microsporidial spores.
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Affiliation(s)
- Ruchi Mittal
- Kanupriya Dalmia Ophthalmic Pathology Laboratory, Mithu Tulsi Chanrai Campus, LV Prasad Eye Institute, Bhubaneswar, India
| | - Sunil Agarwal
- Department of Pathology, Hi-Tech Medical College and Hospital, Odisha, India
| | - Kalandi Ch Muduli
- Kanupriya Dalmia Ophthalmic Pathology Laboratory, Mithu Tulsi Chanrai Campus, LV Prasad Eye Institute, Bhubaneswar, India
| | - Srikant Sahu
- Cornea and Anterior Segment Services, Mithu Tulsi Chanrai Campus, LV Prasad Eye Institute, Bhubaneswar, India
| | - Sujata Das
- Cornea and Anterior Segment Services, Mithu Tulsi Chanrai Campus, LV Prasad Eye Institute, Bhubaneswar, India
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Dutta A, Das S, Priyadarshini SR. Stromal microsporidiosis: a differential for disciform keratitis. BMJ Case Rep 2020; 13:13/9/e237396. [DOI: 10.1136/bcr-2020-237396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Leroy J, Cornu M, Deleplancque AS, Bart A, Loridant S, Fréalle E, Dutoit E, Gaillot O, van Gool T, Puisieux F, Labalette P, Sendid B. Case Report: Ocular Microsporidiosis: Case in a Patient Returning from India and Review of the Literature. Am J Trop Med Hyg 2018; 99:90-93. [PMID: 29692301 DOI: 10.4269/ajtmh.18-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Microsporidia are protists close to the kingdom of fungi that may cause eye infections. Most cases are reported in Asia and affect both immunocompromised and immunocompetent patients. Here, we report a rare case of microsporidial keratoconjunctivitis in an immunocompetent French patient 3 weeks after returning from India. In our patient, Weber trichrome staining of conjunctival scrapings revealed rounded elements approximately 1-3 μm in size. Conventional polymerase chain reaction analysis by ribosomal RNA subunit sequencing showed 100% identity with Vittaforma corneae. Treatment by corneal debridement combined with fluoroquinolone eye drops allowed complete resolution of the lesions. Although rare, ocular microsporidiosis should be investigated in a patient who is native to Asia or has returned from an endemic area and presents with keratoconjunctivitis of undetermined etiology.
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Affiliation(s)
- Jordan Leroy
- Institut National de la Santé et de la Recherche Médicale, Unité 995-Lille Inflammation Research International Center, Fungal Associated Invasive & Inflammatory Diseases, Lille, France.,Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | - Marjorie Cornu
- Institut National de la Santé et de la Recherche Médicale, Unité 995-Lille Inflammation Research International Center, Fungal Associated Invasive & Inflammatory Diseases, Lille, France.,Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | | | - Aldert Bart
- Department of Medical Microbiology, Section Parasitology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Séverine Loridant
- Institut National de la Santé et de la Recherche Médicale, Unité 995-Lille Inflammation Research International Center, Fungal Associated Invasive & Inflammatory Diseases, Lille, France.,Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | - Emilie Fréalle
- Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | - Emmanuel Dutoit
- Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
| | - Olivier Gaillot
- Service de Bactériologie, Lille University Hospital, Lille, France
| | - Tom van Gool
- Department of Medical Microbiology, Section Parasitology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Pierre Labalette
- Service d'Ophtalmologie, Lille University Hospital, Lille, France
| | - Boualem Sendid
- Institut National de la Santé et de la Recherche Médicale, Unité 995-Lille Inflammation Research International Center, Fungal Associated Invasive & Inflammatory Diseases, Lille, France.,Service de Parasitologie-Mycologie, Lille University Hospital, Lille, France
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