sign in sign up
<<
Home , Dirofilariasis

Jebmh.com Case Report

A WORM IN THE EYE- A CASE STUDY OF FOUR CASES Segharipuram Ranganathan Krishnamoorthy1

1Professor, Department of Ophthalmology, Mount Zion Medical College, Chayalode, Adoor, Kerala, South India.

HOW TO CITE THIS ARTICLE: Krishnamoorthy SR. A worm in the eye- a case study of four cases. J. Evid. Based Med. Healthc. 2019; 6(13), 1102-1104. DOI: 10.18410/jebmh/2019/230

PRESENTATION OF CASE Case 3 Case No. 1 A forty-five-year-old lady came to eye clinic with complaints of swelling in the outer aspect of left upper eyelid of 3 month’s duration. It was to begin with a small sized one, of about 6 mm x 6 mm size, gradually increasing in size, now the size was 1.5 cm x 1 cm., painless even on the day of presentation. She came to see the author for the first time.1,2 Swelling was firm in consistency and moving in both, vertical and horizontal directions with ease. There were no associated findings of the adnexa or within the eye. Patient was residing in a slum. She was advised about surgery aswell. After getting her consent, she was subjected to routine blood examinations, including TC, DC, ESR. The total count was 12,000 cells/cmm, DC: P 54, L30, E16. Peripheral 6 smear showed reasonable increase in eosinophils. With Figure 1 these findings, she was taken to the operation table and the swelling was opened. The moment the knife opened the sac, A fifty-year-old man came to the eye clinic in 2010 with something wriggled out immediately. Alas! It was a worm complaints of pain, redness, watering, and a history of visual and an alive worm! The worm was caught in a sterile bottle discomfort of right eye of one-month duration, which was and it exhibited swift movements showing that it is a live fleeting in presentation. On examination the eyelids showed worm. The wound was sutured after removing the sac in mild oedema, conjunctiva was suffused.6 There was a total. Post-operative period was uneventful. The marked circum-corneal congestion, the anterior chamber histopathological examination revealed the identity of the was slightly turbid, with a mild cellular reaction. The worm repens. intraocular tension was 12 with applanation tonometer. The visual acuity of Right eye was 6/24, and the Left eye was Case No. 2 6/9. Slit lamp examination showed the features of anterior Three years later in 2004, a young man 24 years of age uveitis with cells, flare, irregular pupil with posterior came with swelling of right upper eyelid of seven months synechiae and the media was hazy. Hence, fundus duration. It was painless, slowly progressing and with a examination was hazy. Apart from these symptoms and cystic feel in consistency.3,4,5 He too was investigated for signs, there was none on his first visit. He was treated as a routine blood examination with the following results TC case of acute anterior uveitis. Four months later he came 11500 cells/cmm, DC-P56 L32 E12, ESR 15 mm/hr, back with similar symptoms and similar findings. This time Peripheral smear had mild eosinophilia. Again, this case was the author could find out something which he could not see also operated. This time with a growing suspicion of a worm last time the anterior chamber had flare, cells ++ and also inside the mass. Truly after the smallest nick on the surface the author noticed a worm lying in the floor of the anterior of the mass the worm suddenly wriggled out of the wound. chamber. So, it was decided to constrict the pupil and he The worm was collected into the sterile bottle with much was taken to the operation theatre and remove the worm. fight and sent for histopathological examination. This also The patient’s eye was opened, and the worm wriggled out revealed the identity of . in a flash out of the anterior chamber. This worm too was sent to the pathology. In came the result as Dirofilaria Financial or Other, Competing Interest: None. repens. The same patient had been investigated with the Submission 07-03-2019, Peer Review 09-03-2019, positive finding of ESR 20 mm/hr. All other tests were within Acceptance 16-03-2019, Published 01-04-2019. normal limits. Corresponding Author: Dr. S. R. Krishnamoorthy, Professor, Department of Ophthalmology, Case 4 Mount Zion Medical College, A forty-two-year-old man came to the author’s private clinic Chayalode, Adoor, Kerala, South India. E-mail: [email protected] 5 years back in 2013, with complaints of defective vision of DOI: 10.18410/jebmh/2019/230 right eye since 2 months. He was a manual labourer. He was investigated for his eye complaints. Visual acuity right eye 6/12, left eye 6/9 right eye no improvement with glasses.

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 13/April 01, 2019 Page 1102

Jebmh.com Case Report

Hence it was proposed to dilate his right eye to see the Manzonian one, it transmits the third stage filarial larvae fundus. Fundus revealed normal disc and cup with macula of dirofilarial immitis into the blood stream of the showing signs of macular oedema, and a linear streak was definitive host, which is invariably a domestic dog, even seen just above the macula under indirect ophthalmoscopy. though a wide variety of animals and humans can be This streak was showing sinuous wriggling movements in a infected. Thus penetrating into wound created by the slow phase moving through the retina. There was no bite. Now the third stage larvae undergo two more photographic device to capture the rare sight. His blood moulting and develop into adults. They in this form live picture was total count 12000 cells, DC P60, L28 E02, ESR in the pulmonary arteries where they can live up to 5-10 10 mm/hr. years, at the same time the female worms produce more and more microfilariae which can be seen in the Differential Diagnosis peripheral circulating blood. Now in the case of a human 1. , bite, these microfilariae follow the same process and 2. Dirofilaria repens migration pathway as in the case of canine host finally 3. Dirofilaria tenuis ending up in human lungs. Dirofilaria immitis is one of 4. Dirofilaria ursi many species which will cause infection in dogs and 5. humans. Most of the human cases had been reported 6. Acanthamebiasis from eastern United States species. But there is another 7. Toxoplasmosis species of parasite, Dirofilaria repens which is closely 8. related to Dirofilaria immitis. 9. River blindness. 2. Dirofilaria Repens- During a blood meal the same PATHOLOGICAL DISCUSSION mosquitoes introduces the third stage filarial larvae of Here we have seen four patients who had eye problems Dirofilaria are person to the skin of the definitive host presenting as cases of eyelid swellings, intraocular humans or dogs and in them they undergo similar inflammation and a rare sight of a worm wriggling through moulting and reside in subcutaneous tissues. Adult the layers of retina as seen through indirect females measure 100 -170 mm in length and 550 to 650 ophthalmoscopy. This was all during the periods of not so mm width, males are usually 50 -70 mm long and 370- advanced techniques prevalent in a rural set up. So 450 mm wide. In subcutaneous tissues they reside, and whatever information one could gather was from internet. females produce more microfilariae over their life span. Dirofilaria repens usually manifests as either a wandering 1. Dirofilaria Immitis- When the infected mosquito bites worm in the subcutaneous tissue or a granulomatous may be an Aedes, Culex mosquito, the anopheles or the swelling.

Figure 2

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 13/April 01, 2019 Page 1103

Jebmh.com Case Report

3. Dirofilaria Tenuis- During a blood meal an infected 8. - There is another helminth parasite that mosquito (Aedes, anopheles and others) introduces the can involve the eyes. This disease is called Toxocariasis. third stage filarial larvae of Dirofilaria are pens onto the This is seen everywhere and mostly seen in domesticated skin of the definitive host in raccoons or in humans also. dogs and cats. The parasite enters the human body by In the definitive host they become adults similar to the eating food contaminated with soil which harbours the others described earlier. The adult lives in subcutaneous eggs of them along with animal faeces. These eggs tissue, females measuring 80 -130 mm x260-360 mm hatches in the intestines of human beings and allowing wide, males 40-50 mm long x 190-260 mm wide and the larvae to migrate to other parts of human body. But remaining a wandering state or remain encapsulated in usually avoids the eye the subcutaneous tissue or a granulomatous nodule or may be seen. DISCUSSION OF MANAGEMENT Since all the groups had clinical findings of Dirofilaria 4. Dirofilaria Ursi- Is a filarial that parasitizes repens, they were given a course of diethyl carbimazole the subcutaneous tissues and is vectored by black flies in 100 mg thrice daily for three weeks. Fortunately, all of them many parts of the USA and Japan and has suggested did not turn up. that D. ursi has the potential to subsequently infect humans in the form of subcutaneous parasitic FINAL DIAGNOSIS granulomas, potential hosts being marine fishes, mainly The author had come across four cases of worms in salmon However, these cases are now thought to be different types of presentations of worms in the eye. These caused by a closely related parasite. cases may be rare in our part of country. These cases help us to highlight the message that any swellings on the 5. Loa Loasis- This disease is caused by a helminth eyelids of some duration, or an intraocular inflammation parasite mostly in Africa. An infected fly bites and should be treated with utmost caution and a thorough and transmits the infection. Once inside the body, these detailed slit lamp examination and direct and indirect parasites continue its multiplication and migrate to ophthalmoscopy also should be done to clinch the various tissues. These parasites multiply and produce diagnosis. more microfilariae. Both the adult worm and its larvae can produce eye problems like pain in the eyes, impairing REFERENCES the eye movements, besides causing visual complaints [1] Ittyerah TP, Mallik D. A case of subcutaneous like sensitivity to light. dirofilariasis of the eyelid in the South Indian state of Kerala. Indian J Ophthal 2004;52(3):235-236. 6. River Blindness ()- There is one rare [2] Soylu M, Ozcar K, Yalaz M, et al. Dirofilariasis: an cause of blindness caused by a helminth. It is known as uncommon parasitosis of the eye. Br J Ophthalmol river blindness. It is also known as Onchocerciasis. Not 1993;77(9):602-603. seen in our country, but is seen Middle East, South [3] Jariya P, Sucharit S. Dirofilaria repens from eyelid of America, Central America, and parts of Africa One can a woman in Thailand. Am J Trop Med Hyg acquire this disease when the person is bitten by an 1983;32(6):1456-1457. infected blackfly. These larvae of the parasite burrows [4] Iddawela D, Ekambaram K, Wickramasinghe S. through the human skin and there they develop into Human ocular dirofilariasis due to dirofilaria repens in adult worms. They move into different tissues. Sri Lanka. Asian Pac J Trop Med 2015;8(12):1022- 1026. 7. Gnathostomiasis- This is caused by another helminth [5] Khurana S, Singh G, Bhatti HS, et al. Human parasite that is mostly found in Asia, in particular South subcutaneous dirofilariasis in India: a report of three East Asia, Thailand, and Japan. It can also be found in cases with brief review of literature. Indian Journal of certain parts of Africa, South America and central Medical Microbiology 2010;28(4):394-396. America too. A person acquires this infection by eating [6] Seema KM. A case of pediatric ocular dirofilariasis. raw or undercooked meat or fish. The parasite getting Kerala Journal of Ophthalmology 2017;29(2):136- out of the gastrointestinal system thereby moving to 138. other parts of human body including the eyes. Once such thing happens, the patients end up with blindness, either partial or complete blindness.

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 13/April 01, 2019 Page 1104