|Year : 1953 | Volume
| Issue : 4 | Page : 103-109
A new manifestation of the oculo-glandular syndrome
CB Dhurandhar, BT Maskati
Dept. of Ophthalmology, K. E. M. Hospital, Parel, Bombay, India
|Date of Web Publication||12-May-2008|
C B Dhurandhar
Dept. of Ophthalmology, K. E. M. Hospital, Parel, Bombay
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dhurandhar C B, Maskati B T. A new manifestation of the oculo-glandular syndrome. Indian J Ophthalmol 1953;1:103-9
Parinaud (1889) described an infective conjunctivitis of probably animal origin, usually of uniocular incidence. The conjunctivitis was accompanied with granulations which progressed at times to ulceration and associated with enlargement of regional lymph nodes and a moderate fever which persisted for weeks. The glandular enlargement progressed to sluggish suppuration. The disease was however self limiting. Parinaud himself described no pathological findings and defined no bacteriology.
Subsequently, several workers tried to establish the pathology and bacteriology in cases presenting a similar clinical picture. More and more etiological factors were described in different cases having a great similarity in the clinical picture.
Gifford (1898) gave it the name of Parinaud's Conjunctivitis and since that time similar conjunctivitis with retrotarsal granulations, regional lymph adenitis, and fever irrespective of its &tiological agent, has been cal'ed Parinaud's Oculo-glandular Syndrome.
Several conditions were classed under this syndrome such as sporotrichosis conjunctivitis, leptotrichosis conjunctiva (Verhoeff, 1941), oculo-glandular tularemia, tuberculosis and syphilitic conjunctivitis, conjunctivitis due to B. pseudotuberculosis rodentum, conjunctivitis due to Pascheff's organism (Francis, 1942). Theodore (1945) described a yeast-like organism responsible for Parinaud's oculoglandular syndrome. Lymphogranuloma venereum .( Macnie. 1941 ) and catscratch disease as described by Cassdy and Culbertson ( 1953 ) are also known to give rise to Oculo-glandular symptom complex but these can be easily differentiated from the rest by Frie's test and cat-scratch fever antigen test, respectively. In majority of cases, however, a thorough search for the causative organism has been of no avail and the origin of the disease is still surrounded in mystery.
With the newer methods of virus detection and culture the concept of a virus origin for oculo-glandular syndrome is shaping. Sir Stewart Duke-Elder (1928) has predicted that several more varieties of this symptom-complex will probably emerge in future with etiologies at present unknown.
During the last three years, we have come across about 500 cases which presented a clinical picture and pre-auricular adenopathy resembling the Parinaud type but distinct from it because of absence of fever and suppuration of the lymph gland. Out of these we have been able to investigate and study the clinical course in detail in 151 cases. Bacteriologically, 215 cases were investigated, which included the cases of oculo-glandular syndrome to be described presently and other cases of conjunctivitis which were taken as controls.
| Clinical Manifestations|| |
History : As can be seen from [Table - 1] majority of the cases are to be found between the ages of 15 and 40 years. The complaint usually starts with a foreign body sensation, which may be due to a mild trauma with or without a foreign body or with conjunctival soreness. As regards habitat of the patient no definite data could be gathered that was of any importance. No history of contacts with any domestic animal was present.
Onset : In all cases the onset is acute and most of the patients attend the out-patients' department within 4 days of the attack as can be seen from [Table - 2]. All the patients had the attack for the first time, and there was no history of recurrence.
Seasonal Variation : Most of these cases are met with during the summer months.
Symptoms : The patient gets marked photophobia and complains of pain in the eye, which is more marked along the upper lid.
Ocular Suns : In the majority of cases, the condition is unilateral. In our series, out of 151 cases, both eyes were affected in eleven cases only, out of which 6 cases were bilateral at their attendance, the duration of the attack being over 4 days in all cases. In five cases the condition became bilateral during observation. In all the eleven cases both preauricular lymph glands were enlarged and tender.
In a typical case of oculo-glandular syndrome as we see in our department, there is (edema of the lids, particularly the upper one, which considerably narrows the rima palpebrarum. The palpebral and bulbar conjunctive are so markedly congested that the eye presents a rather frightening appearance to the doctor and the patient. However, there is hardly any hypertrophy of the follicles. In some cases the bulbar conjunctiva is suffused suggesting a sort of chemotic appearance. The eye ball is slightly tender but the movements are neither restricted nor painful. There is a profuse lacrimation but usually no mucous discharge. A few cases show a serofibrinous exudate. There are no subconjunctival haemorrhages or any ciliary injection. The cornea remains clear and the corneal sensation, anterior chamber, iris, pupils, fundus and vision remain unaffected. The preauricular lymph node is enlarged and tender. The gland becomes palpable on the third day of the attack.
Course : For about six to eight days the ocular condition goes on gradually worsening, which makes the patient anxious. The preauricular gland also increases in size-from just being palpable on the 3rd day to the size of a pea within 8 to 10 days- -and in most cases gives a firm nodular feel which is usually tender, but the patient does not complain of pain. In a few cases the tenderness extends to the whole parotid gland.
After the eighth to the tenth day of the attack the ocular condition gradually begins to subside giving great relief to the patient. Ultimately by the end of the second or third week, the eye condition becomes normal except for a slight congestion of the lower palpebral conjunctiva.
The pre-auricular gland becomes less tender but remains enlarged for a month or so. In a few cases, it was palpable even at the end of the second month. The recovery is spontaneous. At no time the preauricular gland breaks down or suppurates.
Complications: In no case was any ocular complication detected.
| Investigations|| |
I. Conjunctival Discharge and Scraping
In all the cases, the conjunctival discharge and scrapings were taken, smears prepared from them and the material planted on bloodagar and incubated at 37º C. The smears were stained usually with Gram's stain, some also with dilute Giemsa and Zeil Neilson stains.
Smears: Most of the smears from the 151 cases showed some polymorphs, mononuclears and some epithelial cells. None of the smears showed any inclusion bodies and the bacteriological findings were negative in all cases.
Culture : The culture media after incubation at 37° C. for 48 hours were sterile in all cases in spite of the large number of polymorphs. -
In the 64 control cases of conjunctivitis without glandular enlargement, the conjunctival discharge was also studied bacteriologically in a similar way which showed the presence of B. Koch-Week in 37 cases, B. Morax-Axenfeld in 17 cases, Staphylococci in 7 cases and Pneumococci in 3 cases.
II. Biopsy of Preauricular Lymph Nodes
In our series of 151 cases, only 21 enlarged preauricular glands were removed to study its bacteriology and pathology.
Technique : The gland is localised by palpation and surface-marked with methylene blue on the skin overlaying it. Under infiltration anaesthesia, the gland is found in its capsule beneath the parotid fascia, embedded in the parotid tissue. It is identified by its congested rather purplish colour, and oval shape. In those cases where sinus catarrh is present, the gland is soft and friable, but in those in which chronic lymphadenitis is found the consistency is firm. The gland is removed and then cut into two with all aseptic precautions. From the pulp which appears soft and congested to the naked eye, a smear is prepared and also the material implanted on blood agar medium for culture. Smears from the conjunctiva and from the culture are stained with Gram's, Hxmatoxylin-eosin and Zeil Neilson's stains. The other part of the gland is put in Bouin's fluid and later paraffin sections are prepared for pathological study.
Findings : In all the 21 smears studied no organisms were detected, and no growth was seen in the cultures at the end of 48 hours. In the control cases, out of 37 cases of Koch-Weeks' conjunctivitis six cases had enlargement of the preauricular gland. In only one of these cases a biopsy of the enlarged lymph gland was done and Koch-Weeks' organisms were recovered from the cultured material.
The report on the microscopic study of sections of sixteen glands thus studied showed
only congestion in 7 cases,
congestion with hemorrhages in 4 cases,
chronic lymphadenitis in 2 cases,
sinus catarrh in 3 cases.
| Diagnosis|| |
We have not been able to throw any light on the pathogenesis of this condition. On account of the combination of two factors- a conjunctival lesion with preauricular adenopathy and also unilateral occurrence we have labelled the condition as Oculo-Glandular Syndrome. None of the cases showed complete similarity with the condition described by Parinaud and other workers subsequently.
The type of onset without gland suppuration, the gradual subsidence of the attack and ultimately uneventful recovery represents one more manifestation of the syndrome as predicted by Sir Stewart Duke-Elder.
These cases can easily be mistaken for conjunctivitis. The unilaterality of the condition, absence of hypertrophy or granulation in the conjunctiva, absence of any corneal complications, lack of discharge, negative bateriological findings, distinguishes it from the usual catarrhal conjunctivities.
Absence of any contact with domestic animals and absence of involvement of the inguinal lymph glands distinguishes this variety from the conjunctivitis of lymphogranuloma venereum and cat-scratch fever.
| Prognosis|| |
All cases had a complete spontaneous recovery. There were neither complications nor recurrences.
| Treatment|| |
The following is a record of 68 cases which have been treated with different remedies and followed up fully :[Table - 3]
All the above drugs except Cortisone seemed to have no effect on the condition when compared with the untreated cases. Cortisone seemed to curtail the duration of the disease, and the eye became normal in about 8 days after its commencement. Cases not treated with Cortisone went through the course of 2-3 weeks and appeared to subside thereafter. In two cases the duration appeared to be shortened after removal of the preauricular lymph gland but from this we cannot cone to any conclusion as the number is too small.
| Comments|| |
The variety of oculo-glandular syndrome described as found in our hospital is different from that described by Parinaud and several others. In our series, a conjunctival lesion accompanied by preauricular lymphadenopathy has been described. There was no systemic reaction, like fever, in any of the cases. There were no granulations and ulceration of the conjunctiva, thus deferring from all the conditions hitherto described under Perinaud's Oculo-glandular Syndrome.
Enlargement of preauriculars which drain the conjunctiva is very uncommon in catarrhal or purulent conjunctivitis of bacterial origin, although transient swelling of the node is occasionally met with in hordeola, particularly of the internal variety (Thygeson, 1947 ). We found that the preauriculars were enlarged in only 6 cases of Koch-Weeks' conjunctivitis. Enlargement of the nodes is however characteristic of certain special types of conjunctival diseases especially those caused by viruses and fungi. In our cases the nodes were palpable though not visible, and were slightly tender suggestive of a virus or fungus infection.
At first sight it appears an alarming condition to the patient and a cause of considerable discomfort. Since it is a self-limiting condition, free from any complication an early diagnosis is important in order to prevent anxiety to the patient and also to prevent unnecessary treatment.
The slight tenderness of the eye ball, the suffused and chemotic appearance of the conjunctiva suggests that the pathological change is in relation to conjunctiva and the adjacent Tenon's Capsule.
As regards transmission it does not appear to be contagious. Usually only one member of the family is affected and the disease is not transmitted from patient to patient as in most conjunctival diseases. Contact with domestic animals does not seem to play any part. Thus by process of exclusion and by its seasonal variation it appears to be an air-borne infection.
Finally the negative bacteriological findings, the seasonal variation, and the ineffectiveness of the ordinary line of treatment with a self-limiting nature of the disease suggest a virus as the probable etiological agent. Further experimental work on laboratory animals is being carried out.
We thank Dr. N. M. Purandare, Professor of Pathology and Bacteriology, Seth G. S. Medical College, for helping us in preparations of histological sections and Mr. Bhandarkar for preparing the photographs.
| Summary|| |
In all 151 cases of a yet another manifestation of the Oculo-glandular Syndrome have been investigated and followed up and a description of how it differs from the variety described by Parinaud and others has been given.
The bacteriological findings of the conjunctival discharge and the material from the preauricular gland have been negative.
There is no response to the usual local and general medicament, except perhaps to Cortisone locally.
The recovery is spontaneous in three weeks without any complications.
The probable viral nature of the infection and its mode of transmission are commented upon.
| References|| |
Cassdy, J. V. and Carl S. Culbertson ( 1953 ): Arch. of Ophth.. 50: 68-74.
Duke Elder. Sir Stewart ( 1938 ): Text Book of Ophthalmology, Vol. 2, pp. 1629, 1630. Henry Kimpton, London.
Francis. E. ( 1942 ): Arch. of Ophth., 28: 711-741.
Gifford (1898 ): Amer. J. Ophth., 15: 193 and ( 1924) Brit. J. of Ophth., 8: 350.
Macnie, J. P. ( 1941 ): Arch. of Ophth., 25: 255-279.
Parinaud ( 1889 ): An. d'oc. ci, 252 as quoted in 2.
Theodore, F. H. ( 1945): Arch. of Ophth., 33: 471-475.
Thygeson, P. ( 1947 ): J.A.M.A., 133: 437-441.
Verhoeff, J. P. ( 1941 ): Arch. of Ophth., 25: 1-6.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1], [Table - 2], [Table - 3]