A Mirror of Hospital Practice

^EYE COMPLICATIONS OF DERMAL The most striking point is1 the presence of nodule? in the vicinity of the limbi and these have sprea to form a pannus and to form a, superficially deeply ' interstitial . Vascularization is very marke L. EVERARD f.r.c.p. > By NAPIER, (Lond.) and as the disease has progressed it has gradua1 E. O'G. KIRWAN, c.i.e., m.d., B.ch., f.r.c.s.i. extended around the cornese. The sclera approximate?>a LIEUTENANT-COLONEL, I.M.S. the is involved in part and the disease probably originated from here as an episcleritis. . and The and iris are very ciliary body slightly o there are some but no evidenceinvolve^ G. m.b. d.t.m. posterior synsecliire SEN, (Cal.), active . There is no anaesthesia and very to little pain. The left eye is more affected than Mohi Uddin, male, aged 20 years, was admitted on right eye. 7th July, 1939, to the hospital attached to the Calcutta 0 The clinical picture might on first examination >, School of Tropical Medicine. He gave no history of 1? confused with trachoma or if it were not kala-azar, but a vague history of some undiagnosed leprosy, the presence of fever in childhood. Nodules began to appear on typical post-kala-azar dermal-lel?j. maniasis nodules on the face and body, different parts of his body about five years ago. patient's on closer observation the appearance is very differ?11,' Present condition.?He had a distinct reddish flush photophobia and epiphora althoug of his cheeks and and at after Blepharospasm, chin, times, exposure present were not marked signs. to the sun, his whole showed this flush. He had ' body Treatment.?He was gr- dermal-leishmaniasis nodules and given potassium iodide, ^ typical post-kala-azar t.d.s.; the dose was gradually increased until by depigmented areas all over his face and Those tj1A body. 18th day he was taking gr. xxx, t.d.s., which dose on his and those at the skin-mucous- face, especially took for 14 days. On the 24th day of the iodide membrane were smooth reddish bullous c?i1Il0 junctions, he was given neostibosan 0.3 g. every other day up soft and to but formed of solid ^va g nodules, rubbery feel, 12 doses. After a further month's interval he though loose-textured tissue. The eyelids were involved given urea stibamine, doses up to 0.2 g., on alterna in these his eyes were and he kept swellings, watery, days for 12 doses. . them half closed (vide 2 and g plate XXXI, figures 3); During the interval, one or two isolated he had photophobia. no"^|C? also, were injected with 2 per cent berberine sulphate. A nodule was removed from his chin; a smear made injected nodules shrunk slowly but did not disappea1- from the cut surface of this nodule showed abundant Progress.?After a month of potassium iodide, leishmania. patient felt very ill and his face was swollen. ^fL Both cornea; showed numerous opacities; the right improved immediately the iodide was discontinued, had a pannus all round the periphery, and the left was noticed that the lesions were slightly reduced. was almost completely opaque from the nodular growth After the second course of antimony the skin con"1 it. was covering half of There marked vascularization. tion was distinctly better and he left hospital. ... ' The vision in the left eye was almost nil but improved Re-admission.?He was re-admitted on 6th July, l^y to 'counting fingers at one metre'; in the right eye the nodules had by then nearly disappeared (figure vision was only sufficient for him to walk alone with but his sight was still poor and he was anxious to h?v difficulty, but it improved to 3/60. further treatment with the idea of improving this- eyes He was sent to the eye hospital on 20th September, Figure 1, plate XXX, shows the condition of the 1939: at this time the eye condition was as follows:? at this time. * are He was again sent to the eye with a reque Both upper eyelids somewhat thickened, but the hospital ^ that the over his cornea should be remove lower eyelids are normal. The palpebral conjunctive growth for examination for the of Ieishmania. . are not involved, and the bulbar conjunctiva; are only presence j The diffuse nodule on the left was incise affected in the vicinity of the limbi. The cornea; show large eye at the limbus and a small of the a diffuse haziness, multiple marked pannus piece opacities,, tissue removed. Smears from this tissue inflammat^eshowed tn extending all round the periphery, deep vascularization of Ieishmania. and infiltration into the substantia propria. presence Plate XXX

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leishmaniasis. KeratitisKeratitis duedue toto dermaldermal leishmaniasis.

L.E. R.E. L.E.

1. Fig. 1. Plate XXXI

S \1

Fig. 4.?Showing condition at time of re-admission. Fi"Fig. 2.?Showing2.?Showing: condition on first admission.

condition on final discharge- Fia;.Fi

stikreatment.?He was given 20 injections of amino- from the earlier lesions ever takes place, and to Jffi' each, on alternate days from 7th August the question of auto-inoculation need not be when he was discharged. \t 1 ?e.Pternber, considered as the lesions are non-ulcerative. As i\v._ time of discharge his sight was much further lmP.roved (figure 5). the cornea is a non-vascular tissue, the leish- ?On the 20th September, 1939, the vision mania cannot have been there from the time of the visceral infection and in this case extension E. 3/60: L. E. 1/60 from the sclera must have taken place, as occurs ^ treatment on the 20th July, 1940, the vision in tuberculous episcleritis. The response of the dermal lesions to treat- E. 6/36: E. E. 2/60 ment was characteristically slow, but, as is the the condition was Comment.?This was a fairly typical case of usually case, eventually . and in this instance the ?st-kala-azar dermal leishmaniasis;* in Bengal, cured, eye lesions also "as been calculated (Napier, 1931) that showed considerable improvement and possibly aj 0ut after a of time these will have 5 per cent of persons suffering from kala- lapse improved but we have now lost tj^ar, .eventually develop the local lesions. If further, track of this r0 .story is correct the patient recovered from patient. 0 Had this condition been left we visceral infection without any specific treat- untreated, do not that it would have followed this is not unusual, for about 25 per cent anticipate course described ofent; a the by for neither j. Patients with this condition give similar Duke-Elder, nor abscess formation occur in .0ry- The bullous lesions are not seen ulceration post- ag kala-azar dermal leishmaniasis donovani as the ordinary nodular lesions, (L. frequently whereas the former is the rule in ^is patient also showed, but are not rare, infection), a I oriental sore it is however the photo-sensitive flush is quite common, (L. tropica infection); ^ that the infiltration and vascularization tli uncommon feature in this case was probable 01}ly of the cornea would have further and of the eyes. proceeded ^condition blindness. ? re^erence in the literature to leishmanial eventually produced complete inf fe to be rare. On the 6^e aPPear REFERENCES suh-Ctlons?f leishmanial . keratitis, Duke-Elder (jqogC^ Napier, L. E. (1931) .. Indian J. Med. Res., 19, 1. in his well-known textbook writes :? Duke-Elder, W. S. (1938). A Textbook of Ophthal- 2. involvement by Leishmania is very rare, mology, Henry Kimp- ThP?rnea^ London. by ^?de of infection is not proven, but it is probably ton, oCci ?ct inoculation from the fingers: it does not Persons who have had the disease, and the corj,1 ,ln. confers Tjje ]? ^faction subsequent general immunity. olca^ .P^ture produced is characteristic (Chams, 1929)C with irritative of Phot . a.rting symptoms pain, phi 0Phobia and lacrimation, a superficial erosion or a ^vhieti ^e efflorescence appears on the comea, associated with a deep infiltration. m I l^pkly Centr 'tration pervades the entire cornea, in the or which an abscess forms, which in the? 3rd the w?ek discharges itself either exteriorly or into loss a? ri?r chamber, the result being blindness, or ? e^e- Treatment should be the tion f by applica- atr0D-? antiseptics, as methylene blue with cautp^e' .combined with general arsenical treatment: Scars riZTaf^?n involves the formation of unusually dense of it is undertaken energetically before the end {V e 2nd g0od week the prognosis as regards the eye is is rfp'i lie fair vision may be retained: if its inception until the 4th week more than half of the Caso-0 a^e,d end in perforation.' but^6 ^ave n?t consulted the Chams reference, inf ^FesuiPably he refers to Leishmania tropica ??n' secondary to oriental sore. In this corfr^Jon a of auto-inoculation is recognized mode of the infection. Oriental sore does ,otS^ad?CCUr the *n Bengal and this patient never left due ?r?v*nce. In this case the skin condition is don ai^ hematogenous infection of Leishmania ?Van^- the In this form of dermal leishmaniasis tion assumPtion is that the wide distribu- the leishmania takes place at the time of thp Vls there is no evidence that extension