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Bilateral Acanthamoeba Mark Cachia Markham keratitis Franco Mercieca

Abstract complaints.4,5. Corneal nerve infiltration daily and timolol maleate 0.5% twice is a rare and an immune ring are the typical daily, for both eyes, together with oral eye commonly misdiagnosed signs of this infection. fluconazole 200mg daily. as herpes simplex or fungal keratitis. The following day both eyes showed Failure to include it in the differential Case Report corneal oedema with prominent diagnosis in any contact lens wearer A 17-year old female (MB) corneal infiltration, multiple stromal with the typical features of an eye presented at Mater Dei Hospital with infiltrates and abscesses, with minimal infection, results in a delay in the redness in both eyes, photophobia, fluorescein uptake. A working diagnosis appropriate treatment with eventual severely impaired vision and of bilateral fungal keratitis was made, complications and even blindness. excruciatingly painful eyes. The patient and topical amphotericin B 0.1% was This report describes the first case of denied any previous ocular trauma added on an hourly regime in addition bilateral Acanthamoeba keratitis ever and was not on any steroid treatment to the previous . The patient reported in Malta, which occurred in a before. MB also stated that she swam was referred to a corneal specialist for young female contact lens wearer. with the contact lenses three days prior an opinion who in addition, also noted presentation. bilateral corneal nerve infiltrates and Introduction On examination, both eyes were an immune ring in the right eye. These Acanthamoeba keratitis (AK) watery but there was no discharge. A findings changed the working diagnosis is a rare, acute sight-threatening slit-lamp examination of the left eye to bilateral acanthamoeba keratitis. infection of the cornea, caused by the revealed multiple abscesses while that At this point, the topical Acanthamoeba species – an organism of the right showed multiple abscesses dexamethasone was stopped and ubiquitously found in the environment.1,2 with corneal oedema. Corneal atropine 1% twice daily together Approximately 85% of cases are scrapings which were carried out were with dibromopropamidine 0.15% associated with the use of contact negative for Gram stain and culture. twice daily were added. In the lenses.3 The initial symptoms are often MB was admitted, prescribed topical meantime, propamidine isethionate, nonspecific, with redness, tearing, moxifloxacin 0.5% three times daily, 0.02% and 0.02% disproportional excruciating pain, and topical dexamethasone 0.1% three polyhexamethylene were photophobia being the most common times daily, ciprofloxacin 750mg twice ordered from abroad as they are

14 unavailable locally. Corneal scrapings are liberated from the cysts, and an eye infection should be screened were repeated the next morning adhere to the contact lens surface.2,3,11 for Acanthamoeba keratitis in order with the following being sent for When wearing the contact lenses, to avoid serious complications. investigation: one scalpel blade plus numerous trophozoites and cysts are Awareness of such a condition must two fluid samples from the right eye, apposed to the corneal surface, and therefore increase among general and two scalpel blades plus one in the presence of a minor epithelial practitioners, optometrists and fluid sample from the left (enough defect, the amoebae make their ophthalmologists. material was collected from one fluid way into the anterior stroma of the Following a strict disinfecting sample). The results were positive for corneal epithelium.2,3,11 The parasites procedure on a regular basis (ideally Acanthamoeba polyphaga in the right then phagocytose and deplete the instructed by an eye specialist), eye. No bacteria/fungi were grown. keratocytes, starting anteriorly then avoiding any water contact with the After waiting for the medication to proceeding deeper into the cornea. The contact lenses/cases and ensuring the arrive from abroad (16 days following devitalized stroma is quickly infiltrated use of proper disinfecting solutions, admission), MB was started on by inflammatory cells followed by should allow adequate protection the standard treatment for bilateral stromal necrosis from leukocytic and against this sight-threatening condition. acanthamoeba keratitis, i.e. topical aparasitic collagenolysis.3,5 Other recommendations of note 0.02% chlorhexidine and topical The fact that the patient swam with include the frequent changing of the 0.02% polyhexamethylene biguanide the contact lenses, only three days lens storage cases, avoiding overnight every two hours and topical 0.1% before symptoms started, strongly contact lens wear and maintaining propamidine isethionate every hour. suggests that this might be the main strict personal hygiene especially when Atropine and dibromopropamidine were causative factor. MB also claimed that handling the lenses and cases. still being administered to the patient. the disinfecting procedure she used An improvement was noted within with the lenses and cases was not in four days, at which point atropine and accordance with the manufacturer’s References dibromopropamidine were stopped guidelines. In fact MB sometimes 1. Da Rocha-Azevedo B, Tanowitz HB, Marciano-Cabral F. Diagnosis of while topical fluorometholone acetate missed disinfecting the lenses after use, caused by pathogenic free-living amoebae. 0.1%, acyclovir 3% ointment and and instead placed the lenses in their Interdiscip Perspect Infect Dis. 2009:251406. 2. Bottone EJ, Madayag RM, Nasar Qureshi M. ciprofloxacin 750mg were prescribed cases after use. Moreover, it cannot Acanthamoeba keratitis: synergy between amebic and bacterial cocontaminants in twice daily for both eyes. 21 days after be excluded that the patient made use contact lens care systems as a prelude to admission, the patient was discharged, of an expired contact lens solution. infection. J Clin Microbiol 1992;30(9):2447- 2450. with further follow-ups both locally and These three factors probably made the 3. Garner A. Pathogenesis of acanthamoebic keratitis: hypothesis based on a histological abroad at the Moorfields Eye Hospital invasion by Acanthamoeba an easier analysis of 30 cases. Brit J Ophthalmol. in London. task. The solution used by our patient 1993;77:366-370. 4. Lindsay RG, Watters G, Johnson R, Ormonde contained neither SE, Snibson GR. Acanthamoeba keratitis Discussion nor 3% – two and contact lens wear. Clin Exp Optom. 2007;90(5):351-360. Acanthamoeba species are ingredients proved to be very effective 5. Mutoh T, Ishikawa I, Matsumoto Y, Chikuda 6 10-13 M. A retrospective study of nine cases of extremely resistant protozoa , and exist for soft lenses. It is acanthamoeba keratitis. Clin Ophthalmol. in two forms – the active trophozoite of concern that companies producing 2010;4:1189-1192. 6. Sriram R, Shoff M, Booton G, Fuerst P, form, and the inactive cystic form. The contact lens solutions are not required Visvesvara GS. Survival of acanthamoeba cysts after dessication for more than 20 years. latter is reported to be resistant even to to demonstrate activity against J Clin Microbiol. 2008;46(12):4045-4048. contact lens solutions, antimicrobials Acanthamoeba. 7. Ibrahim YW, Boase DL, Cree IA. Factors 7,8 affecting the epidemiology of acanthamoeba and the majority of antiamoebals. Treatment of bilateral AK is often keratitis. Ophthalmic Epidemiol. 2007;14:53- A breach in the corneal epithelium difficult because of the possibility 60. 8. Sharma S, Srinivasan M, George C. Diagnosis is not a prerequisite for Acanthamoeba of long term therapy and toxicity of acanthamoeba keratitis – a report of four 12,13 cases and revirew of literature. Indian J infection, however, contactlens-induced of antiamoebic medication. The Ophthalmol. 1990;38:50-6. changes in the cornea may partly time which elapsed from onset of 9. Wahid AW, Abdul Qader AAM, Shaharuddin B, Wan Hitam WH. Incidence and clinical explain how the organism invades the symptoms till starting treatment against features of contact lens related microbial 8,9 keratitis. International Medical Journal. eye. AK probably allowed deeper stromal 2008;15(3):221-223. Contamination with Acanthamoeba invasion by the organism, making 10. Martin S, Barr O. Preventing complications in people who wear contact lenses. Br J Nurs. in itself does not cause any discomfort medical therapy more difficult. The 1997;6(11):614-619. to the contact lens wearer2,4 however, fact that specific anti-AK drugs are not 11. Gray TB, Cursons RTM, Sherwan JF, Rose PR. Acanathamoeba, bacterial and fungal proteins building up from tear readily available in Malta could have contamination of contact lens storage cases. Brit J Ophthalmol. 1995;79:601-605. secretions on the surface of the lens played a role in allowing the infection to 12. Joslin, CE., Tu EY, Shoff ME et al. The act as a culture medium for bacteria10 invade deeper into the cornea. association of contact lens solution use and acanthamoeba keratitis. Am. J. Ophthalmol. and other microorganisms. These 2007;144(2): 169-180. 13. Hassanlou M, Bhargava A, and Hodge microorganisms are then utilized Conclusion WG. Bilateral acanthamoeba keratitis and by Acanthamoeba for growth. The It is imperative that any contact lens treatment strategy based on lesion depth. Can J Ophthalmol. 2006;41:71-3. trophozoites, in favourable conditions, wearer presenting with the features of

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