"Demodicosis" Mimicking PreSeptal Cellulitis: Severe Periocular and Facial Inflammation Caused by "Normal" Skin Flora

Due to their relatively high prevalence and commensalism, the pathogenicity of Demodex mites has been debated. Recent data, however, show Demodex to be associated with skin and ocular surface diseases such as rosacea, blepharitis, and keratitis. Here the authors report the first known case, to the best of the their knowledge, of Demodex infestation mimicking preseptal cellulitis in an adult human. A 29-year-old male bilaterally blind from advanced retinopathy of prematurity presented with a 2-month history of right-greater-than-left upper eyelid and periocular/cheek swelling, redness, and ocular discharge that did not resolve with oral antibiotics or oral steroids. Based on MRI findings, biopsies of the right lacrimal gland, right orbital fat, and right upper eyelid preseptal skin were obtained which revealed marked intrafollicular Demodex mite density and budding yeasts in the upper eyelid skin. This case serves to alert clinicians to this entity that may not otherwise be usually considered in ophthalmic clinical practice.

Pediculosis pubis: presentation to ophthalmologist as pthriasis palpebrarum associated with corneal epithelial keratitis

Pthiriasis palpebrarum caused by infestation with Pthirus pubis (crab louse) draws attention to pediculosis in the pubic and inguinal region. As pthiriasis is usually transmitted by sexual contact, many cases are likely to have other sexually transmitted diseases. A multidisciplinary approach is essential in the management of these cases. In this case report, we highlight the above and report for the first time associated keratitis.

Lesson of the month 2: Chronic erythematous painless plaque on the eyelid co-presenting with multiple ulcerated nodules on the extremities

Cutaneous leishmaniasis is a parasitic disease caused by the Leishmania species, transmitted by the bite of an infected sandfly. The typical cutaneous lesion is a painless ulcer with a raised, indurated margin and often covered with an adherent crust. The lesions are mostly located on exposed sites such as the face and the extremities. Eyelid involvement is rare, making up only 2-5% of cases with facial cutaneous leishmaniasis. Herein, we report a 50-year-old male who presented with an erythematous plaque on the upper eyelid and multiple ulcerated nodules located on the extremities. Following microscopic examination of the lesional smear, a diagnosis of cutaneous leishmaniasis was made, and the patient was successfully treated with intramuscular meglumine antimonate therapy.

Ocular surface discomfort and Demodex: effect of tea tree oil eyelid scrub in Demodex blepharitis

The purpose of this study was to evaluate the relation between ocular discomfort and ocular Demodex infestation, and therapeutic effects of tea tree oil (TTO) in Demodex blepharitis patients. Three hundred and thirty-five patients with ocular discomfort were evaluated for ocular Demodex infestation and subjective symptoms with ocular surface discomfort index (OSDI) score. Among them, Demodex-infested patients were randomized to receive either eyelid scrubbing with TTO (TTO group,106 patients) or without TTO (Control group, 54 patients) for 1 month. Demodex were found in 84% of patients with ocular discomfort. The number of Demodex was significantly correlated with age (P = 0.04) and OSDI score (P = 0.024). After eyelid scrub treatment, Demodex count was reduced from 4.0 ± 2.5 to 3.2 ± 2.3 in the TTO group (P = 0.004) and from 4.3 ± 2.7 to 4.2 ± 2.5 in the control group (P = 0.27). Also, OSDI score was reduced from 34.5 ± 10.7 to 24.1 ± 11.9 in the TTO group (P = 0.001) and from 35.3 ± 11.6 to 27.5 ± 12.8 in the control group (P = 0.04). In conclusion, Demodex number showed a significant positive correlation with age and subjective ocular discomfort. The tea tree oil eyelid scrub treatment is effective for eliminating ocular Demodex and improving subjective ocular symptoms.

Furuncular myiasis: a case report

Most clinicians associate myiasis with travel to a tropical location. We report a case of endemic myiasis due to Cuterebra species to remind clinicians that myiasis can occur throughout North America.

Ocular cysticercosis: an unusual cause of ptosis

A nine-year-old girl presented with pain, unilateral ptosis, inflammation of the upper eyelid and restricted ocular motility. She was diagnosed to have ocular cysticercosis by magnetic resonance imaging of the orbit, which showed a well-defined ring-enhancing lesion in the superior rectus muscle of the left eye. Enzyme-linked immunosorbent assay for serum antibodies against cysticercus was positive. The patient improved dramatically on a therapeutic trial of albendazole and oral steroids. There was a history of spontaneous extrusion of the cyst five days after starting therapy. The conjunctival defect healed without any surgical intervention.

Myiasis of the upper eyelid

Myiasis rarely occurs in the eyelids. We report a 3-year-old girl with a myiasis of the upper eyelid after a trip to Central America. A 1.5 cm larva of a Dermatobia hominis was excised. Infestation with D. hominis should be suspected when a localized swelling with a central fistula in an eyelid is present in patients who have been to Central and South America.

[Efficiency and application safety of Cepan cream. Observation of a new indication]

Cepan Cream has been applied in therapeutics for 20 years. This drug is used for topical treatment of burn scars and keloids as well as post-operative scars and contractures. Cepan produces a multidirectional effect. Cepan is well tolerated. Pharmacological property analysis of active ingredients, results of physical, biochemical studies and clinical estimation indicate that the evaluated preparation is both effective and safe. Lately, new information on Cepan effectiveness in eyelids inflammation caused by parasite Demodex folliculorum has been particulary interesting.

Isolated optic neuritis from an identified Gnathostoma spinigerum

PURPOSE

To describe a patient with isolated monocular optic neuritis caused by an identified Gnathostoma spinigerum infestation.

CASE REPORT

A 21-year-old man developed a swollen eyelid and painful monocular visual loss of his left eye which did not improve after treatment by intravenous steroid and albendazole. A remarkable eosinophilia in his peripheral blood count was demonstrated. The patient subsequently found a live parasite emerged from his lower eyelid and it was successfully removed by himself. Gross and histopathology examinations of the obtained parasite was undertaken. The parasite was identified as Gnathostoma spinigerum. His blood test for Gnathostoma antibody was positive.

DISCUSSION

The etiology of isolated optic neuritis in this patient was Gnathostoma spinigerum which was confirmed by the histopathology of the obtained parasite and the positive serologic test.

CONCLUSIONS

We could identify the exact parasite that was proven to cause an isolated optic neuritis. The immediate removal of a causative parasite maynot result in an improvement of the injured tissue but is beneficial in preventing further destruction as well as future complications.

A case of subcutaneous dirofilariasis of the eyelid in the South Indian state of Kerala

This report describes a case of dirofilariasis of the upper eyelid of a young female patient from Kerala. This is probably the first reported case from India in which a live dirofilarial worm was recovered from the subcutaneous tissues of the eyelid.

[Subcutaneous myiasis. A case report]

Although myiasis or hypodermiasis is a parasitic disease that theoretically has practically been eradicated, a new case has recently been reported in Lower Normandy, in a bovine husbandry region.

CASE REPORT

A seven-year-old-girl was hospitalized in November 1998 for an edema of variable size on the right eyelid, which was not painful and non-inflammatory, with accompanying ptosis. A number of subcutaneous nodules were found on the forehead above the right eye socket. The right eye itself was unaffected. The symptoms had evolved over a ten-day period. Further examination did not detect any sign of eosinophilia, and the hypodermiasis and toxocariasis serologies were negative. The clinical evolution was characterized by the regression and reappearance of the edema on several occasions, after which the edematous mass became progressively larger, more swollen and painful, so that it was no longer possible to open the eye. The subcutaneous nodules partially disappeared when the edema increased in size. Six weeks after the onset of clinical signs, eosinophilia was observed and the hypodermiasis serology was positive. Due to the limitation of the visual field as a result of the edema, a short-term steroid treatment (seven days) was orally administered. The patient recovered, and no further edematous signs were noted. However, contrary to what had been reported in the literature, the larvae did not appear on the surface of the skin.

CONCLUSION

In conclusion, in bovine husbandry regions the diagnosis of hypodermiasis should always be kept in mind in the event of clinical signs indicative of larval migration, even in the initial absence of eosinophilia, and even with an initially negative hypodermiasis serology. This disease should soon be eradicated, as regional bovine treatment programs have been set up to systematically treat the cattle and eliminate the larvae.

South American cutaneous leishmaniasis of the eyelids: report of five cases in Rio de Janeiro State, Brazil

PURPOSE

To describe American cutaneous leishmaniasis of the eyelids and highlight the main clinical and diagnostic features of lesions, which are rare in this location.

DESIGN

Retrospective, noncomparative case series

METHODS

Leishmanin skin test, touch preparations, histopathologic analysis, and culture in appropriate media were used for clinical confirmation and parasitologic diagnosis. Positive cultures were identified by the iso-enzymes technique. All patients were treated with pentavalent antimony applied intramuscularly.

RESULTS

Leishmanin skin test was positive in all five patients. Touch preparations, histopathologic analysis, and culture were performed in four patients. Touch preparations were positive (presence of Leishman's bodies) in two patients; histopathologic analysis showed a granulomatous infiltrate in four patients and parasite was present in two patients; culture was positive in three patients, and in two the parasite was identified as Leishmania (Viannia) braziliensis. Therapy was effective for all patients.

CONCLUSIONS

Cutaneous leishmaniasis of the eyelids is uncommon in the Americas. The disease may present diagnostic difficulties when appearing in nonendemic areas. The clues for diagnosis are the clinical aspect of lesions, the epidemiologic data, and a positive Leishmanin skin test. Demonstration of parasite is not always possible. Pentavalent antimonial compounds are the therapy of choice. Formerly, transmission of leishmaniasis occurred only when humans penetrated forested areas and became an incidental host. Now, eyelid lesions are part of the changing pattern in the transmission of the disease. With the increase in ecotourism, these lesions may begin to be seen in air travelers returning to other parts of the world.

Palpebral myiasis

Myiasis is most prevalent in Mexico, central and south America, tropical Africa, and the southwestern United States. Although dermal myiasis is rare in most of the United States, it is a disorder that may be seen in international travelers. In the United States, external myiasis is usually caused by the cattle botfly. We report here a case of ophthalmomyiasis involving the left upper eyelid of a child. We examined a six-year-old boy who presented to the Massachusetts Eye and Ear Infirmary (MEEI) in September 1998. He complained of persistent swelling of his left upper eyelid for the previous ten days. The edema and erythema were unresponsive to warm compresses and oral antibiotics. Ocular examination revealed a mild preseptal cellulitis of the left upper eyelid with a small draining fistula. On slit-lamp examination, we found one larva protruding intermittently from the fistula site. The larva was extracted with forceps, wrapped in a moist towel and sent in a jar to the parasitology laboratory. The specimen was identified as a Cuterebra larva by a parasitologist at the Harvard School of Public Health. One week later, the patient's eyelid edema and erythema had completely resolved.

Tick infestation of the eyelid

PURPOSE

To report the rare occurrence of tick infestation of the eyelid margin.

METHODS

A 58-year-old woman was initially examined with a small yellow lesion of the left upper eyelid margin that appeared after she felt a sting near her eye. Close examination disclosed an insect body attached to the eyelid margin. En bloc excision of the insect with part of the eyelid was performed.

RESULT

Gross examination of the specimen identified the organism as the nymph stage of a bloated tick of the genus Hyalomma but of an uncertain species.

CONCLUSION

Ticks (Hyalomma) can become embedded in the meibomian gland orifice and manifest as a mass at the eyelid margin.

Demodex sp. in California ground squirrels

An undescribed species of Demodex (Acari: Demodecidae) was observed in hair follicles and ducts of sebaceous glands in the ear canals of seven California ground squirrels (Spermophilus beecheyi) from Santa Clara County, California (USA). The animals had died of unrelated causes and were submitted for necropsy between September 1994 and February 1996. Similar mites were observed in the lumens of hair follicles and ducts of Meibomian glands in the eyelids of two of these squirrels. Microscopic changes in the epithelium and surrounding dermis, when present, were minimal. No associated clinical signs of disease or macroscopic lesions were observed. To our knowledge, this is the first report of Demodex sp. in a ground squirrel.

Human subcutaneous dirofilariasis caused by Dirofilaria repens in Ibiza, Spain

A case of human subcutaneous dirofilariasis contracted in Ibiza, Spain is reported. An incomplete nematode extracted from the eyelid of a woman patient was identified on the basis of its anatomic and histologic characteristics as a nongravid adult female of the species Dirofilaria repens. The subcutaneous location of the worm, together with the epidemiologic data, support this finding.

First report of immature Thelazia skrjabini (Nematoda: Thelazioidea) from the eye of a white-tailed deer, Odocoileus virginianus

The eyes from 103 hunter-killed white-tailed deer (Odocoileus virginianus), and 19 mule deer (O. hemionus) killed between 28 November to 14 December 1991 from Wainwright, Alberta were examined for Thelazia spp. One immature male and two immature female Thelazia skrjabini were collected from beneath the third eyelid of one adult female O. virginianus. This is the first report of T. skrjabini in a member of the Cervidae.

Integumental lesions caused by ectoparasites in a wild population of the side-blotched lizard (Uta stansburiana)

Histopathological effects of ectoparasites on integument were examined for a wild population of the side-blotched lizard Uta stansburiana. These included the trombiculid Neotrombicula californica, the pterygosomatid mite Geckobiella texana; the macronyssid mite Ophionyssus natricis (Macronyssidae) and the ixodid tick Ixodes pacificus. A diffuse inflammatory response occurred at the site of chigger and tick attachment which consisted of histiocyte, heterophil, fibroblast and lymphocyte infiltration that often extended into the dermis. Granuloma formation also was noted. The most prevalent parasite was N. californica which frequently occurred in large aggregations above the eyelids. Ectoparasites were most abundant from February through April.

Leishmania major: the suitability of East African nonhuman primates as animal models for cutaneous leishmaniasis

The susceptibility of four species of East African nonhuman primates to experimental infection with Leishmania major was investigated. Four Syke's monkeys (Cercopithecus mitis), two vervet monkeys (Cercopithecus aethiops), two baboons (Papio cynocephalus), and two brown bushbabies (Galago garnettii) were each inoculated intradermally on the left eyelid, left ear, and nose with 0.1 ml of medium containing 1 x 10(7) promastigotes of a characterized L. major strain. All the nonhuman primates except the bushbabies developed erythema and conspicuous nodules on the eyelids and ears by 3 weeks PI. The nodules increased rapidly in size and ulceration was evident on the eyelids and ears by 49 days PI in the vervets, Syke's, and baboons. The aspirates were positive in culture or smears at 35, 49, 63, and 77 days PI. No parasites were observed in cultures or smears at 92, 105, 128, 147, and 161 days PI. The lesions in these animals began resolving by 84 days PI and were completely healed by 112 days PI. The exception was one baboon in which lesion healing did not start until around 147 days and was completely healed by 182 days PI. Cultures from the liver failed to demonstrate visceralization of the parasite in any of the animals throughout the 68 weeks of the experiment. Challenge with the same strain of L. major 6 months PI, corresponding to about 3 months after self cure, failed to produce infection in any of these experimental hosts. All the nonhuman primates except the bushbaby when challenged with the same strain of L. major at 12 months PI developed lesions and were positive for parasites at 14 and 28 days PI. Positive cultures were obtained from the eyelid and ear of one vervet up to 42 days PI. However, the lesion sizes in all these animals were smaller than in the initial infection and did not ulcerate. The nodules disappeared within 6 to 8 weeks as compared to 16 weeks in the initial infection. The histopathological appearance of the lesions varied from diffuse infiltration of plasma cells and lymphocytes which increased progressively to granulomata with epitheloid cells. This study shows that the vervets, Syke's, and the baboons are equally susceptible to L. major infection, while bushbabies are refractory. The vervets, Syke's, and baboons demonstrate a self-healing phenomenon within about 3 months which is comparable to that observed in humans infected with L. major. These three species of nonhuman primates are therefore considered as suitable models for drug or vaccine trials against human zoonotic cutaneous leishmaniasis.

Sheep tick in the eyelid

The uncomplicated removal of a tick, Ixodes ricinus, from the lid is described. Methods of removal of ticks, their natural history, and potential complications are discussed.

Besnoitia sp. from goats in Kenya

The eyelids of goats in Kenya contained several, conspicuous white cysts which were up to 1.5 mm in size. By histological and electron microscopical studies it was confirmed that these cysts belong to the genus Besnoitia.

Dirofilaria repens from the eyelid of a woman in Thailand

An immature male Dirofilaria repens was removed from a cystic mass in the eyelid of a 51-year-old woman employee of a rubber plantation in Phangnga Province, southern Thailand.

Incidence of Demodex folliculorum on skin of lids and nose

The incidence of follicle mites (Demodex) has been studied in 206 non-selected subjects by means of adhesive tape impressions on skin during daytime of nose and lids and moist storage of the tape. The incidence was seen to rise with increasing age: 4% in young subjects, 30% in the age group of 20 to 80, and 47% in older. The mite was more often present on the skin of the nose (17%) than on that of the upper lid (8%), while the incidence on the lower lid was between these 2 extremes (13%). A total of 126 Demodex mites were detected (123 Demodex folliculorum and 3 Demodex brevis), all full-grown. Of these, 41% were ghosts. The migration was evenly distributed in all directions within the areas examined. About 0.2% of the mites can be roughly estimated to have migrated at a certain point of time from the follicles of the nose to its skin.

Demodex folliculorum in hair follicles of eyelid skin

Although Demodex folliculorum is a common inhabitant of eyelid hair follicles, it has received scant attention by ophthalmologists in recent years. I examined 100 biopsies of eyelid skin for the presence of these mites. The incidence of infestation increased with age; 84% of all cases and 100% of cases over age 70 years were involved. No organisms were seen in sebaceous or meibomian glands. I found no pathologic changes except for follicular distention and hyperkeratosis and occasional mild chronic perifolliculitis. Circumstantial evidence for incriminating Demodex in human disease is good, although scientific proof is lacking.

A survey of thelazia worms in the eyelids of British cattle

Thelazia skrjabini and T gulosa were found in the eyes of 237 of 566 bovine heads (41.9 per cent) examined in a Surrey abattoir during 1976. The prevalence of infection increased during late June, July and August, when a new generation of worms emerged in eyes. The burden in eyes ranged from one to 170 worms, with a mean count of 10.44 +/- 3.23. Worms were found behind and in third eyelids and in the lacrimal ducts of lower eyelids, which makes their detection very difficult by clinical examination. They were significantly more common in cattle 21 to 38 months old than in those less than 21 months old. Lesions occurred in 14 of 327 (4.3 per cent) infected eyes. No worms were seen in eye washings from cattle in nine herds experiencing outbreaks of keratoconjunctivitis.

Loiasis. Report of a case and review of the literature

An adult worm was isolated from the left upper eyelid of a man, eight years after he had left an area in which L loa is endemic. We described his case in order to draw attention to some differences between reported features of the disease in areas in which the worm is endemic and in areas in which it is not.

Onchocerca cervicalis infection in horses from the western United States

In a study of Onchocerca cervicalis infection in a sample of 100 horses from the western United States, 48 were infected. Infection was more common in older horses and occurred in both sexes equally. Data about the distribution and the concentration of microfilariae within the skin are presented. The only cutaneous pathologic change that could be attributed to microfilariae was minimal perivascular inflammatory cell infiltrate. Invasion of the eye with microfilariae occurred in 60 percent of the infected horses. An attempt was not made to relate microfilarial invasion of the eye with ocular pathologic changes.