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   Table of Contents      
BRIEF REPORT
Year : 2003  |  Volume : 51  |  Issue : 1  |  Page : 87-88

Polymicrobial keratitis in an HIV-positive patient.


Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Correspondence Address:
R Tandon
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


PMID: 12701872

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  Abstract 

We describe a case with non-responding polymicrobial spontaneous corneal ulceration in an HIV-positive patient. Acanthamoeba was among the microorganisms isolated.

Keywords: Keratitis, HIV-positive, Acanthamoeba, spontaneous ulceration.


How to cite this article:
Tandon R, Vajpayee RB, Gupta V, Vajpayee M, Satpathy G, Dada T. Polymicrobial keratitis in an HIV-positive patient. Indian J Ophthalmol 2003;51:87-8

How to cite this URL:
Tandon R, Vajpayee RB, Gupta V, Vajpayee M, Satpathy G, Dada T. Polymicrobial keratitis in an HIV-positive patient. Indian J Ophthalmol [serial online] 2003 [cited 2020 Jun 4];51:87-8. Available from: http://www.ijo.in/text.asp?2003/51/1/87/14728

Spontaneous ulcerative keratitis in the absence of ocular predisposing factors is a rare but known manifestation of Human Immunodeficiency Virus (HIV) infection. Organisms isolated from infected corneas include Candida albicans , Candida parapsilosis , Staphylococcus aureus, Pseudomonas aeruginosa, Capnocytophaga and alpha-hemolytic streptococci.[1],[2],[3] A Medline search of the literature did not reveal any other reported case of Acanthamoeba keratitis in an HIV-positive individual.


  Case report Top


A 25-year-old man presented with a history of spontaneous onset of pain, redness, watering and photophobia and decreased vision of one month's duration in the right eye. He had consulted several ophthalmologists and been prescribed various medications but had not responded to treatment. He denied any history of associated systemic illness but had a history of treatment for central nervous system tuberculosis.

The visual acuity in the right eye was counting fingers close to the face and was 6/12 in the left eye. Examination of the right eye revealed central stromal keratitis with an overlying epithelial defect, two ill-defined satellite infiltrates temporal to the central lesion and fresh keratic precipitates. Corneal sensation was diminished. A clinical diagnosis of Herpes simplex keratitis with the possibility of bacterial and fungal super-added infection was made.

Corneal scrapings were obtained for microscopic examination (Gram's staining and potassium hydroxide wet mount), Herpes simplex antigen detection test, and culture on standard media including non-nutrient agar with Escherichia coli overlay. Gram-positive cocci and filamentous septate hyphae were visible on microscopy. Antiviral (3% acyclovir eye ointment 5 times a day), antifungal (5% Natamycin eye drops 1 hourly), fortified antibiotics (5% cephazolin and 1.3% Tobramycin eye drops one-hourly round the clock) and cycloplegic were prescribed. When reviewed three days later, symptoms had improved marginally. Bacterial culture had grown coagulase-negative staphylococcus sensitive to cephazolin and tobramycin. Herpes simplex antigen detection test was negative. Antiviral therapy was stopped. The rest of the treatment was continued.

One week later the patient reported with excruciating pain. The corneal ulceration had worsened [Figure - 1] and the satellite lesions coalesced. Further results of microbiological investigations were positive for Fusarium solanii and Acanthamoeba . He was hospitalised and 0.1% Amphotericin B, 0.1% Propamidine isethionate and 0.02% Polyhexamethyl biguanide (PHMB) eye drops were instituted on an hourly basis. A second review of past medical records suggested that in addition to cerebellar tuberculosis 10 years earlier, he had contacted pulmonary tuberculosis a year earlier. There was also a history of sexual promiscuity and previous unprotected contacts with multiple commercial sex workers. There was no history of intravenous drug abuse. In consultation with an internist HIV testing was done by ERS (ELISA/rapid/simple) assay[4] using three different enzyme linked immunosorbent assays (ELISA). The patient's sample was reactive in all the three tests and was positive for HIV-1 antibody.[4] The CD4 count was 453 cells/mm 3. Serological testing for Herpes simplex, Cytomegalovirus and Toxoplasma antibodies were negative.

Meanwhile, the corneal ulcer progressed despite the above treatment, and perforated. Emergency penetrating keratoplasty was performed using an 8.5 mm donor button sutured with 16 interrupted 10.0 nylon sutures in a 7.5 mm recipient bed. PHMB eye drops were continued in addition to routine post-keratoplasty medication.

No systemic medication for the HIV infection was administered because of economic constraints. The patient and family were counselled regarding the nature and prognosis of the infection. After 6 months' follow-up the graft was clear with a best corrected visual acuity of 6/60.


  Discussion Top


The patient represents a case of polymicrobial keratitis including Acanthamoeba infection in a promiscuous young heterosexual HIV-positive male with a history of recurrent tuberculosis. Acanthamoeba keratitis has not been reported so far in HIV-positive patients.

Acanthamoeba keratitis is usually associated with a local predisposing factor but sometimes may occur spontaneously.[5] Spontaneous corneal ulceration per se is known to occur in association with HIV infection. [1],[2],[3],[6] Mixed infections with more than one pathogen have been known to occur in patients with acquired immuno-deficiency syndrome (AIDS).[3] Acanthamoeba corneal infection has also been documented to have coexisting bacterial isolates[7] but associated fungal infection is not common. The polymicrobial infection and delay in identifying Acanthamoeba may have been the cause for the poor response of the ulcer to treatment in this case.

Corneal manifestations of AIDS include non-infectious peripheral corneal ulcers.[6],[8] Herpes Zoster ophthalmicus , Herpes Simplex keratitis, keratoconjun-ctivitis sicca,[8] and infectious corneal ulcers. [1],[2],[3]Acanthamoeba is a known opportunistic organism in HIV-infected patients.[9] This is the first report of Acanthamoeba keratitis in an HIV-positive patient. We wish to emphasise the importance of comprehensive history-taking in patients who develop ulcerative keratitis in the absence of any local predisposing factors and highlight the possibility of associated HIV infection in high-risk cases[Figure - 2].

 
  References Top

1.
Santos C, Parker J, Dawson C, Ostler B. Bilateral fungal corneal ulcers in a patient with AIDS-Related Complex. Am J Ophthalmol 1986;102:118-19.  Back to cited text no. 1
    
2.
Parrish CM, O'Day DM, Hoyle TC. Spontaneous fungal corneal ulcers: An ocular manifestations of AIDS. Am J Ophthalmol 1987;104:302-3.  Back to cited text no. 2
    
3.
Aristimuno B, Nirankari VS, Hemady RK, Rodrigues MM. Spontaneous ulcerative keratitis in immuno compromised patients. Am J Ophthalmol 1993;115:202-8.  Back to cited text no. 3
    
4.
Mishra SN, Joshi PC. Guidelines for HIV testing. In HIV Testing Manual. Laboratory Diagnosis, Biosafety and Quality Control. New Delhi: National Institute of Communicable Diseases and National AIDS Control Organisation, Govt. of India, 1999. pp 83-85.   Back to cited text no. 4
    
5.
Jones DB. Acanthamoeba: The ultimate opportunist? Am J Ophthalmol 1986;102:527-30.  Back to cited text no. 5
    
6.
Pflugfelder SC, Saulson R, Ullman S. Peripheral corneal ulceration in a patient with AIDS-related complex. Am J Ophthalmol 1987;104:542-43.  Back to cited text no. 6
    
7.
Illingworth CD, Cook SD, Karabatsas CH, Easty DL. Acanthamoeba keratitits: risk factors and outcome. Br J Ophthalmol 1995;79:1078-82.  Back to cited text no. 7
    
8.
Khadem M, Kalish SB, Goldsmith J, Fetkenhour C, O'Grady RB, Phair JP, et al. Ophthalmologic findings in acquired immune deficiency syndrome (AIDS). Arch Ophthalmol 1984;102:201-6.  Back to cited text no. 8
    
9.
Dunn JP, Holland GN. Ocular Sequelae. In: Merigan TC, Bartlett JG, Bolognesi D, editors. Textbook of AIDS Medicine . Baltimore: Williams & Wilkins, 1999. pp 459-69.  Back to cited text no. 9
    


    Figures

  [Figure - 1], [Figure - 2]


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