|Year : 1981 | Volume
| Issue : 2 | Page : 107-109
SP Dhir, P Talwar, IS Jain
Department of Ophthalmology and Microbiology, Post-graduate Institute of Medical Education and Research, Chandigarh, India
S P Dhir
Department of Ophthalmology and Microbiology, Post-graduate Institute of Medical Education and Research, Chandigarh 160012
|How to cite this article:|
Dhir S P, Talwar P, Jain I S. Ocular histoplasmosis. Indian J Ophthalmol 1981;29:107-9
Ocular histoplasmosis consists of a haemorrhagic or non-haemorrhagic macular lesion with disciform detachment of the sensory retina, peripheral and peripapillary choroidal atrophic scars, and evidence of previous infection of Histoplasma capsulatum. The syndrome has a geographic predilection. In the United States, it seems to appear in an area corresponding to the area of greatest histoplasmin sensitivity.
Systemic histoplasmosis is endemic in the Ohio and middle Mississippi River valley of United States. However, it is a rare disease in India. Only 20 authentic of histoplasmosis have been reported from different parts of the country. No cases of ocular involvement due to histoplasmosis has been reported. The present report describes such a case.
| Case report|| |
S.S. 25 years old male (A-036155) was seen with the complaints of defective vision from the left eye for the last two months. History revealed accidental detection of blurring of vision from left eye following closure of right eye. There was no history of any pain, redness or watering from the eye. There was no history of trauma to the eye. Prior to examination he had recieved treatment in the form of cortico-steroides systemically and subconjunctivally for eleven days without any improvement of deterioration of vision. Concomitantly he also recieved Inj. Neurobion I/M daily for 11 days.
He gave no past history of respiratory problem, diabetes mellitus or bowel complaints. He had malaria 5 months ago and received treatment in the form of chloroquin tablets and Inj. Chloroquin.
On examination no systemic abnormality was found and his blood pressure was 120/80 mm Hg.
Ocular examination revealed a normal right eye with a visual acuity of 6/6. Left eye showed subconjunctival haemorrhage (due to previous subconjunctival injection). Anterior segment was quiet. Pupil was larger than the right eye and reacted sluggishly to direct light. Consensual reaction was brisk. Fundus examination revealed a clear media with normal optic disc and periphery. Macular area showed serous detachment with gross oedema and radial folds around the fovea. A dense yellowish spot could be barely made out below the macula [Figure - 1]. Fluorescein angiography showed a small triangular hyper fluorescent patch below and temporal to the fovea. A small neovascular membrane was seen below this patch [Figure - 2]. There was progressive leakage of the dye from the neovascular membrane and from the triangular hyper-fluorescent patch which changed its size and configuration [Figure - 3]. The overlying retinal capillary network was normal. Central field examination showed a peracentral scotoma in the upper temporal quadrant involving the fixation spot.
Laboratory investigations showed a normal haemogram, blood count and E.S.R. of 2 mm. Stool examination revealed presence of entamoeba histolytica cyst and E.coli . X-ray chest showed normal lung fields with enlargement of heart size. Serology for histoplasmosis was strongly positive by immuno-precipitation by gel diffussion technique. The histoplasma antigen for immunodiffusion test was obtained from Microbiological Associates Bethsda, Margland, U.S.A.
The Serological tests by immuno-diffusion for blastomycosis, aspergillosis and candidiasis using cystoplasmic extract were negative.
| Discussion|| |
The diagnosis of ocular histoplasmosis is largely presumptive. It is based on the clinical picture and evidence of previous infection with histoplasma capsulatum, usually in the form of a positive histoplasma skin test. The clinical suspicion was fairly strong in the present patient. A youngman with disciform active lesion on the macula, clear media, demonstration of histo spot and neovascular membrane with fluorescin angiography and tolerance of heavy dosages of corticosteroids without aggravation of the clinical picture in this patient are all the characteristics which are seen in ocular histoplasmosis. However we do have another patient with all the above characteristics and a negative histoplasma serology.
The rarity of this condition in India is understandable as there are only some 20 cases of known histoplasmosis reported in the country and none with ocular involvement. Studies of patients with chronic and acute pulmonary histoplasmosis have failed to reveal any ocular changes over those that are to be expected in a control group,. In the present patient also no active palmonary focus was detected. The eye involvement seems to follow a benign systemic histoplasmosis as evident from the postive serological immuno-preciptation in gel diffusion test in the present patient.
Inspite of strong circumstantial clinical evidence, the pathogenesis of this disorder has remained unresolved. Focal granulomatous choroiditis has been produced in rabbits experimentally infected systemically with spores of histoplasma capsulatum. Focal chorio-retinal lesion by histoplasma capsulatum have also been produced in rabbits by supra-choroidal inoculation. Bhatia et al in a study of histoplasmin skin test in India observed that the centrol group showed 6.7% of positive reactors while uveitis patients showed 7.14% of positive reactors. Histoplasma infection is uncommon in India and ocular involvement is extremely rare. However serological testing of clinically promising patients may yield more cases of this syndrome.
| Summary|| |
A young man of 25 years age with disciform lesion of the macula in left eye and a positive serology for histoplasmosis is reported.
| References|| |
|1.||Schlaegel, T.F., 1975, Internal Ophthalmic Clinics, 15: 1. |
|2.||Edwards, L.G., Acquaviva, F.A.. Livesay. V.T., Cross, F.W., and Palmer, C.E., 1969, Amer. Rev. Respir. Des. 99: 14. |
|3.||Talwar, P., Mishra. S.S. and Dash, R.J., 1978, Ind. J. Bathol. Microbiol. 21 :357. |
|4.||Ouchterlony, O., 1953, Acta Pathol. Microbio. Scand. 32 :232. |
|5.||Davidorf, F.H., and Anderson, J.D., 1974, Trans. Amer Acad. Ophthalmol. Otolaryngol. 78:876. |
|6.||Wong, W.R., Anderson, R.R., Collins, E.M. and Hill, W.B., 1972, Trans. Amer. Acad. Ophthalmol Otoleryngol, 77 :769. |
|7.||Mohan, M; Mazumder, A; Batta, R.K., Mahajan, V.M., and Goswamy. V., 1978, East. Arch. Ophthalmol. 6 : 23. |
|8.||Bhatia, R.P.S., Mehra, K.S., and Tewari, A.K. 1980. Ind. J. Ophthalmol 28:9. |
[Figure - 1], [Figure - 2], [Figure - 3]