Microsporidial Stromal Keratitis: Epidemiological Features, Slit-Lamp Biomicroscopic Characteristics, and Therapy

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.

Primary brain myxoma, an unusual tumor of meningeal origin: case report

OBJECTIVE AND IMPORTANCE

Primary myxoma of the central nervous system is an extremely rare tumor arising from cells of primitive mesenchymal origin. Only two cases of primary intracranial myxoma have been described previously. We report a patient with a primary myxoma originating from the right frontoparietal convexity dura, which we studied in detail with diagnostic imaging and pathological analysis.

CLINICAL PRESENTATION

A female adolescent presented to the emergency department with a 3-day history of mild headache, abdominal pain, and intermittent left-sided focal motor seizures. Neurological examination was remarkable for left leg hyperreflexia and difficulty with tandem gait. Cranial computed tomography and magnetic resonance imaging demonstrated an inhomogeneously enhancing mass in the right frontoparietal region.

INTERVENTION

A right frontoparietal craniotomy was performed. During surgery, a tumor appearing similar to a typical convexity meningioma was completely removed along with the dural attachment.

CONCLUSION

The patient had an uneventful recovery and returned to normal activity. Primary intracranial myxoma should be distinguished from other meningeal tumors and metastatic cardiac myxoma by appropriate pathological analysis and cardiac evaluation. A circumscribed myxoma completely excised with adequate dural margin carries a good prognosis for surgical cure.

A survey of moyamoya disease in Hawaii

Moyamoya disease (MMD) is a rare entity in the US with a few retrospective series and sporadic cases reported in the US and North America. Although it is known that MMD exists in all races, there is a predilection for people of Asian origin. Because of the relatively high percentage of Asians living in Hawaii, it was hypothesized that the estimated prevalence of MMD would be higher in Hawaii than the remaining US. All practicing neurologists, neurosurgeons, neuroradiologists and major hospitals in Hawaii were surveyed for MMD patients treated during the past 10 years. Medical records and angiograms (when available) were reviewed and the diagnostic guidelines for MMD from the Ministry of Health and Welfare of Japan applied. There were 53 records reviewed in 42 patients; 21 fulfilled the criteria for definite Moyamoya disease which were the focus of this study. In Hawaii, the prevalence of MMD was higher in patients of Japanese descent compared to Caucasians (P = 0.012) and higher than in the remaining US (P < 0.001). Non-Japanese Asians and Pacific Islanders had a higher incidence of MMD than Caucasians that was not statistically significant. There was no difference in MMD among Japanese living in Hawaii or Japan. Males had an equal percentage of hemorrhage and infarcts; females tended to have a higher incidence of ischemic events rather than hemorrhage. Age and sex distribution of our series were similar to larger reported MMD studies. Our results suggest that: (1) Moyamoya disease in Hawaii has a higher incidence and prevalence than the rest of the US, largely due to the larger percentage of Asians, particularly Japanese, living in Hawaii; and (2) genetic rather than environmental factors may explain the increased MMD in Hawaii.

Polychromatic corneal and conjunctival crystals secondary to clofazimine therapy in a leper

A 67-year-old man had a diagnosis of dapsone-resistant lepromatous leprosy. He received clofazimine (Lamprene) at a dosage of 100 mg twice daily. After 3 years of therapy, results of slit-lamp examination disclosed myriad polychromatic crystals diffusely involving the cornea and perilimbal conjunctiva of both eyes. Thick sections (1 micron) from a conjunctival biopsy showed numerous rectangular-to-rhomboidal crystals within stromal fibroblasts and macrophages. By electron microscopy, these cells contained elongated, membrane-bound, cleft-like spaces that corresponded to the sites where crystals had been present previously. Additionally, complex lipid inclusions were observed in mesenchymal cells as well as in endothelial cells and pericytes of blood vessels. The ocular side effects of clofazimine therapy are reviewed. Clofazimine-induced keratopathy should be included in the differential diagnosis of patients with polychromatic crystalline deposits in the corneas. To the best of the authors' knowledge, this complication of clofazimine therapy has not been described previously.

[Epidural hematoma without intradural lesions--clinical study of 120 cases]

One hundred twenty cases of epidural hematoma without intradural lesion treated between 1975 and 1983 to which CT scan was available, were presented. Mortality rate was 1.7% and morbidity rate was 6.7%. In all cases of epidural hematoma including with and without intradural lesion in the same term (164 cases), mortality and morbidity rate were 7.3 and 10.4% respectively. Ninety five cases were male and 25 cases were female. Causes of injury were falls from a height (42 cases, 35%), traffic accident (41 cases, 34%), and falls at ground level (24 cases, 20%). The site of hematoma in 120 cases of 128 hematoma were frontal (17 cases, 13%), temporoparietal (74 cases, 58%), parasagittal (4 cases, 3%), middle fossa (8 cases, 6%), occipital (16 cases, 13%) and posterior fossa (9 cases, 7%). Fractures were shown in 109 cases out of 120 cases on skull X-P and depressed fractures were 12 cases. Those which showed no fracture on skull X-P, revealed slow growth of hematoma and delayed onset of clinical signs and were mainly children. Seven operated cases of epidural hematoma does not show fractures on skull X-P nor initial unconscious. Clinical course of disturbance of consciousness were divided in five types as follows; I. no unconsciousness (22 cases, 18%), II. latent interval (17 cases, 14%), III. primary but no secondary unconsciousness (29 cases, 24%), IV. lucid interval (22 cases, 18%), V. unconscious throughout (16 cases, 14%) and unknown (14 cases, 12%). Cases which Glasgow Coma Scale Score were over 7 showed good recovery in Glasgow Outcome Scale.(ABSTRACT TRUNCATED AT 250 WORDS)

Corneal allografts induce cytotoxic T cell but not delayed hypersensitivity responses in mice

In order to study the cellular immune responses induced by corneal allografts transplanted to a nonimmunologically privileged site, we have used a previously described murine heterotopic corneal allograft model. BALB/c (H-2d) corneal allografts transplanted to a vascular graft bed on the thorax of C57BL/6 (H-2b) recipients were rapidly rejected within 14 days, while corneal syngrafts survived indefinitely (greater than 28 days). Analysis of both primary and secondary cytotoxic T lymphocyte (CTL) responses 7, 10, 14, and 21 days after heterotopic transplantation revealed antigen-specific CTL reactivity at all time points tested (P less than 0.01). By contrast, delayed-type hypersensitivity (DTH) responses to corneal alloantigens (footpad swelling assay) were negative (P greater than 0.05) in 83% of the animals tested. The absence of DTH responsiveness to corneal allografts was not a result of the small graft size or antigenic load. Either two or six circular skin allografts (3-mm diam) of BALB/c origin induced both strong CTL and DTH responses (P less than 0.001) in C57BL/6 recipients, while two or six corneal allografts (2-mm diam) induced strong CTL responses, but DTH responses again failed to develop (P less than 0.05) in over 75% of the animals tested. The ability of corneal alloantigens to elicit CTL responses but not DTH reactivity when grafted to a heterotopic site provides a basis for understanding the immune privilege enjoyed by this tissue.

Ocular viral infections

The ocular manifestations of viral infection vary greatly. Involvement of the anterior segment is generally mild and self-limited, except in cases of congenital infection which are often associated with significant alteration of ocular structures or in cases of childhood infection with herpes simplex virus or varicella-zoster virus, in which prolonged inflammation may lead to corneal thinning or perforation, glaucoma and cataract formation. Involvement of the posterior structures is potentially sight-threatening. Retinal or optic nerve involvement should be suspected in any patient who complains of acute onset of blurred vision in the absence of anterior segment inflammation or opacities in the ocular media. Fortunately retinal viral infection is rare in immunocompetent hosts. Optic neuropathy may occur as an isolated sign but is more often associated with more generalized involvement of the central nervous system. While specific therapy is not always available, early diagnosis of ocular viral disease should aid in the amelioration of acute symptoms and prevention of long term complications.

Keratitis in relapsing polychondritis

An 11-year-old girl developed peripheral corneal thinning and superficial pannus formation with no other ocular or systemic signs. During the subsequent two years she developed inflammation of both ears, progressive collapse of the nasal cartilage, and polyarthritis. A clinical diagnosis of relapsing polychondritis was made. A spontaneous perforation of her right eye secondary to progression of peripheral ulcerative keratitis was successfully repaired. Treatment with dapsone, a nonsteroidal anti-inflammatory agent resulted in remission of her ocular and systemic disease.

Composite torsional quartz transducer for shear ultrasonic measurements of aqueous liquids

A composite torsional quartz transducer has been developed for the shear ultrasonic measurements of aqueous solutions in the frequency range from 10 to 100 kHz. In order to prevent the electric interaction and low contact angle between the transducer and water, a torsional quartz crystal transducer is attached to a fused quartz rod whose surface is partly gilded by evaporation. The accuracy of +/-60 dyn/cm2 for the rigidity and +/-0.03 cP for the viscosity is attained by use of this transducer.