|Year : 1960 | Volume
| Issue : 4 | Page : 97-102
Reports to the general assembly of the international organization against trachoma
|Date of Web Publication||5-May-2008|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rostkowski L. Reports to the general assembly of the international organization against trachoma. Indian J Ophthalmol 1960;8:97-102
The International Assembly of the Organization against Trachoma, under the presidency of Professor Bietti, took place on 10-9-58 in Brussels. The programme included 19 reports. The following is a condensed resume of the same and the debates.
The etiological problem in trachoma was the main subject matter. The principal report on this theme was brought out clearly by Thygeson and Nataf. From their own work and from, other 118 critically reviewed and acknowledged works, Nataf presented the present status of the etiologic problem in trachoma. Eighteen short reports on this problem followed the principal report.
| Etiology|| |
Difficulties en researches :- They were (1) lack of suitable experimental animal, (2) lack of typical serological reagents and (3) by the refusal of the. trachomatous virus to develop in vitro.
Pathogenicity :- It is now a proved fact that the pathogenic agent of trachoma is the virus, which appears under two forms (a) the elementary body and (b) the initial body. Both figures, multiplying and developing produce the H.P. or inclusion bodies, which contain a hvdrocarbonic matrix with glycogen. The proof of their, etiologic role is founded on the following facts.
(1) The constant appearance of the inclusion bodies during the initial period of the disease and during exacerbations of chronic old cases, as by artificially activating trachoma by using cortison.
(2) The constant appearance of the inclusion bodies in the human experimental trachoma, produced by the direct transfer of the trachoma materials or filtrates.
(3) The lack of inclusion bodies in the normal conjunctiva and nontrachomatous diseases of conjunctiva, except in inclusion conjunctivitis, where these inclusion bodies also appear.
(4) The disappearance of these bodies after recovery and even during efficacious treatment.
(5) Striking dependence of the number of bodies upon severity of the disease the quantity of conjunctival secretions etc.
Presence of H.P. bodies in trachoma is a feature of human trachomatous infection Only. The lower forms of monkeys are not -sensitive to the trachoma infection. The superior forms of monkeys give possibility to provoke a benign trachoma without cicatrization and corneal changes. Confirmation of the inclusion bodies in experimental trachorr-a presents great difficulties and sometimes fails. It is of interest that the experimental monkey trachoma, after having been transmitted to man shows a great quantity of H.P. bodies. In human trachoma, artificially provoked by conjunctival infections or trachoma materials as well as by the filtrates of this material, the H. P. bodies are always to be seen.
| Diagnosis|| |
Value of Electron Microscopy. The report of Japanese observers Mitsui and Suzuki concerning the researches by electron microscopy, indicate that electron microscopy has so far not added much to our knowledge. In their trachoma study they compared the findnigs of light-microscopy with electron-microscopy. They found no difficulty in identifying elementary inclusion bodies by both methods, but found initial inclusion bodies hard to identify by electron microscopy.
Identification by staining : On the basis of his observations on conjunctival scrapings of 2,000 trachomatous patients, K.C.Agarwal (India) concluded, that Giemsa method is the most reliable. It probably demonstrates all the stages of the vital cycle of the inclusion body as well as associated cytopathological changes.
The iodin method demonstrates the glycogen matrix of the elementary body inclusions and if supplemented by giemsa is very helpful in the identification of inclusions.
| Morphology and the Vital Cycle|| |
Elementary and initial bodies together form inclusion bodies, which can be intra- or extracellular. Elementary bodies are derived from initial bodies by binary fission and the initial bodies then grow and become elementary bodies again. The transformation and development of the lifecycle require about 48 hours.
When stained by Giemsa ELEMENTARY BODIES appear pink, have a diameter approximately 0.25 are remarkably uniform in size, round or oval in shape. They are the smallest visible figures of the pathological trachomatous agent. The INITIAL BODIES stain blue vary in size and shape. The most characteristic extracellular form is a coccobacillary body with a long diameter of z.21L or more, but a variety of other forms are recognized.
The intracellular initial body, which represents probably a young form of the virus, can be discovered singly or multiple in one cell. When multiple, they look like a granulated mass stained blue with Giemsa. Inside this mass are to be seen fine granules stained pink, which are elementary bodies. After entering into the protoplasm of the cell, free elementary bodies increase and multiply developing into initial bodies. The initial bodies increase in size and then decrease by dividing, creating a granular mass stained blue with Giernsa. Inside this mass appear granules stained in pink (elementary bodies). The initial bodies multiply within the epithelial cells so long as they have nourishment. At the end of their development nothing remains in the cell but fine pink granules, the elementary bodies. The elementary bodies multiple and occupy the whole protoplasm, the cell perishes, expulsing the elementary bodies which as free elementary bodies enter the protoplasm of other cells and start their life cycle a new.
Filtrability :- Trachoma virus resists filtration through ordinary bacterial filters except Berkefeld v. After satisfying some technical conditions bacteria-free filtrates could be obtained regularly from trachoma. To fulfil the fist condition it is essential to employ epithetial scrapings rather than follicular expressions, which were often used in earlier unsuccessful filtration experiments.
Reaction to Temperature :- Sensitive to heat the trachoma virus is inactivated at temperature of 50° C within 15 minutes. Inactivation occurs in 2.1 hours at room-temperature and more rapidly at temperature of 57°C.
| Pathological Characteristics of the Virus|| |
Kerato-conjunctival affection : It is known that trachoma is typically a kerato-conjunctivitis and all cases have invariably shown simultaneous corneal and conjunctival changes - keratitis superficialis punctata. This is followed in turn by an edema of the limbus, by subepithelial infiltrates and lastly by extention of limbal vessels. Inclusion bodies H.P are readily demonstrable in scrapings from the limbus and from the cornea. More difficult to define however, are the cases of stage 1 trachoma in young children, in which no changes of the cornea and limbus are to be seen. Inclusion bodies are likely to be difficult to find in limbal and corneal scrapings from such cases, but careful search for them is usually rewarding.
Epithelial predisposition :- Some authors consider trachoma as an epitheliosis with strict localisation of the virus to the epithelial cells in spite of appearing in subepithelial membrane of the conjunctiva in trachoma granulations followed by cicatrization. These authors explain the presence of subepithelial changes by the action of the virus toxin.
Toxin of the Virus :- Postic confirms the presence of toxin in trachoma virus. He found histopathological changes in the ciliary ganglion in the form of lyrnphocitic infiltration, decrease in the number of ganglion cells and degeneration of their kernels. The author explains these changes by the toxic action of the trachomatous virus, which, according to author's opinion, is not only of epitheliotrop nature but afro of a limited neurotrop one
Invisibility of the Virus :- Other authors suggest that the changes in the subepithelial membrane are provoked by the trachomatous virus itself, although it is impossible to confirm the H.P. bodies in trachoma subepithelial membrane even by electron microscopy. The seeming absence of H.P. bodies in the subepithelial membrane is explained by the period of invisibility which trachoma virus passes through. Because of the existence of a periodical virus invisibility it is impossible to confirm the H.P. in trachoma of experimental monkeys. Nevertheless they are likely to be seen when transfering experimental trachoma from monkey to man, 42 day.; after the inoculation-Pages (Rabat).
Cultivation of the Virus :- The provocation of experimental trachoma by vaccination to monkeys is not of much value. The absence of cicatrization, absence of corneal changes and impossibility to demonstrate the H.P. bodies can easily confuse such experimental monkey trachoma with conjunctival folliculosis in such monkeys
According to Nataf's opinion, Collier (England) obtained such a cultivation of the trachomatous virus on the yolksacs of the chic embryo, after some, passages, vaccinating it afterwards on the conjunctiva of a healthy man. In this way he provoked typical trachoma, confirming thereby the presence of H.P. inclusion bodies which included the carboydrate matrix, containing the glycogen. He proved then that the virus cultivated by trachomatous material provoked a typical trachoma of the conjunctiva of healthy man. This Collier's work confirmed the previous work of Tang of China who in 1957-58 cultivated too a trachomatous virus on the chic embryo membrane.
Serological Reactions : Experiments executed by Tsu-Tsui confirm the presence of antibodies in serum of trachomatous patients. He infected his own eves and established that every subsequent infectior evoked a trachoma more benign than the previous one, radically cured. Tsu-Tsui explains this phenomena by the appearance of antibodies in the scram of his own blood after the infection.
In their report Murakani and her collegues confirm too the presence of antibodies in the serum of the trachomatous patients. They have realised a complement fixation reaction (CFT) of the blood serum of 144 trachomatous patients, using the antigen of trachomatous material on the chor:oallantoic of the chic embryo. The authors confirmed that : (1) in 50% of these cases the reactions were positive; (2) the majority of reactions occurred in severe trachoma; (3) cases of trachoma with positive reaction were more resistant against treatment and gave worse prognosis, while cases with negative reaction, easily yielded to treatment and had tendency to recover spontaneously. Prognosis thus depends on the intensity of the CFT.
This work is confirmed by Fujiyama's report who, during 9 years has carried out 121 experiments in his own laboratory, executing 'the passages on the chorioallantoic membranes of chic embryo. 38 experiences showed knots in these membranes. The CFT of these knots with the serum of the trachomatous patients gave positive results in 60%. On the other hand the CFT were always negative either in the suspension of these knotted membranes with the serum of healthy individuals or in the suspension of the non-vaccinated membrane with the serum of healthy individuals or in the suspension of the non-vaccinated membrane with the serum of trachomatous patients.
In the suspension of the infected membranes and after centrifugation, the, presence of small bodies, 50 μ, to 250 µ, analogous to trachoma virus has been found by electron microscopy and confirmed by other observers too. In the control, these small bodies were not to be seen.
Gupta (India) suggested the possibility of cultivation of the trachoma virus on the membrane of the chic embryo ass well as in the increase of the antigen concentration by passages.
Finally basing on the four reports it can be judged that the trachoma virus can be artificially cultivated and that in the blood of trachomatous patients are present trachoma antibodies, which give the .possibility to obtain the specific serological reaction among trachomatous patients.
Resistance:- It is now generally agreed that no race of man is immune to trachoma. A relative resistance in the Negro race however, has been noted by some observers.
According to Mac Callan's view, insufficient nourishment and status lymphaticus are factors not well disposed to trachoma infection. Other authors in their experiences, realised on the monkeys, assert that insufficient nourishment, poor in vitamins, diminish the sensitivity to trachoma infection. The resistance to trachoma in persons affected with blepharikis proceeds probably from the fact that virus growth in the keratinised cells 's not possible.
The Carrier State :-Trachomatologists have not recognised a carrier state in trachoma. No valid evidence has been advanced to indicate that an individual, who has never had clinical trachoma, can be a carrier. It is however difficult to reject the possibility of existing healthy carriers, for the individual apparently healthy can have a hidden non-revealed trachoma.
| Classification|| |
The pathogenical trachoma agent as well as that of inclusion conjunctivitis possess three characteristic virus properties, namely: filtrability, inclusion body formation and obligate cell parasitism. They resemble the rickettsiae by : (1) their susceptibility to certain sulfonamides and antibiotics, (2) the basophilic staining of the inclusion Lo3ies and (3) their intracellular pleomorphic cycle .
A striking resemblance can be seen in the properties of trachoma virus and its near relative, the conjunctivitis virus on the one hand and to the characteristics of psittacosis virus and lymphogranulomatosis 13. V. They all possess elementary and initial bodies and are submitted to the same rum ph0logical changes. The agents of all four diseases are regarded as members of an intermedite group exhibiting some of the properties of rickettsiae and are designated . as a gronp-CHLAMYDOZOACEAE. The trachoma virus of this group is called CHLAMIDOZOON TRACHOMATIS. The trachoma and the inclusion conjunctivitis viruses differ from the other viruses of this group by the presence in their inclusion bodies of the hydrocarbonical matrix, containing the glycogen. The matrix of the other viruses of this group is only of a protein substance. Therefore both these viruses, differing from other viruses of this group, have special affinity with the epithelial cell.
On the other hand the trachomatous virus differs from the inclusion conjunctivitis virus by the former's biological property of causing necrotizing changes in ocular tissues. Thus inclu-n sion conjunctivitis and trachoma are etiologically and clinically well separated.
Relationship of inclusion Conjunctivitis to trachoma: The relationship between trachoma and inclusion conjunctivitis is such a close one, that consideration of one disease cannot properly be undertaken without consideration of the other. It should be noted that etiologic studies of inclusion conjunctivitis have provided data directly applicable to etiologic problems in trachoma, a disease much more difficult to study.
Etiologic types : Are there more than one etiologic types of trachoma?
Nataf and Thygeson assert discovering only one trachoma type, provoked by only one race of trachoma specific virus. A number of factors contributing to differences in the severity of the disease have been suggested. Of particular interest are: (1) the age of onset, (2) racial resistance and (3) secondary infection. Relatively to the activity of these agents the course of the disease tends to be milder or more severe and gives sometimes a quite different clinical picture, and this in the same country, in the same family and even in the patient himself. The same differences can be noted among the individuals in any population or even among the members of single family.
Trachoma contracted in infancy tends to be milder than trachoma contracted in adult life. in the trachoma of the endemic localities, the disease begins by attacking children and is resistant against secondary infection, therefore the course of the disease is milder.
Tsu-Tusi, basing himself on the experiences by electron microscopy suggests the existence of incomplete viruses, which provoke a variable type of trachoma, a mild one, non-infectious and where confirming H.P. inclusion bodies are not to be found.
Gupta also believes in different trachoma-types, provoking in different countries various forms of the disease which are submitted to different treatments. By this way it would be easier to explain one trachoma-type observed by Rachat in Iran in 2,000 children with non-cicatrized disease. The author explains this special type of trachoma by the lack of secondary infections.
Lacrymal Passages in Trachoma
Gall (Hungary) demonstrated interesting observations concerning the disease of the lacrymal canals confirmed roengenoiogically. This method, giving the opportunity to examine the disease of lacrymal canals in vivo, allowed the author to bring about the following conclusions : (1) trachoma of lacrymal canals appears more frequently than it is admitted,(2) trachoma of lacrymal canals is an initial suffering and appears simultaneously with the trachomatous disease of the conjunctiva, (3) trachomatous changes of lacrymal canals regress easily after rinsing them by antibiotics.
The Tarsus in Trachoma:
L'armand (Algier) and their co-workers showed large material of their observations, concerning tarsi of trachomatous patients with entropion. Among 707 cases, the, tarsi were moderate; numerous tarsi were usually thick and only part of them were thinner than normal. The author warns therefore to be careful and not to make thinner the tarsi normally thin, during the entropion operation.
| Treatment|| |
There is no doubt that sulfonamides and antibiotics have greatly improved the treatment and accelerated the recovery. Antibiotics are believed to act on trachoma by interrupting enzyme systems and degenerative changes in the inclusion bodies have been noted. Sulfonamides do not act on trachoma virus in vitro. Antibiotics are more effective when used topically and sulfonamides are more effective when used in a general way. To be effective topically sulfonamides arc to be applied frequently enough throughout the treatment period. Antibiotics, on the other hand, have, been effective even when used two or three times daily as ointment. Some days after using sulfonamides, no inclusion bodies can be found in the scrapings- This disappearance however is but apparent and map be explained by the peeling off of the epithelial cells: and simultaneous disappearance of a number of inclusion bodies. Therefore in spite of this it is necessary 'to use the sulfonamide treatment during further weeks.
Many ophthalmologists confirm a relatively high susceptibility of acute trachoma cases to sulfonamides amt antibiotic action, whereas to chronic trachoma the potency of these drugs is negligible.
As regards the choice between the different antibiotics and sulfonamides, no one drug features prominently. All of them have their enthusiasts in about equal measures. Nevertheless many authors are followers of old methods. Rochat (Iran) is using sulfate of copper with good result. Pines (London) speaks about the Doenig operation of removing trachomatous conjunctiva and grafting the surface with buccal mucous membrane.
| Propagation|| |
Many reports to the Assembly indicate a lowering of the incidence and intensity of trachoma all over the world. This is attributed to the use of sulfonamides and antibiotics, rise in living and educational standards, effective propaganda, perhaps a weakening in potency of the virus, effective measures against infection in children, appreciation of clinical differences between trachoma proper, folliculosis and catarrh of the conjunctival follicles, increased facilities for ambulatory treatment of mild cases and hospitalization of severer cases, propaganda in sanitation and prophylaxis. The corner stone in the fight against trachoma is to issue permanent instructions for all physicians likely to treat trachoma. Measures taken by the author in Poland have already appeared in this Journal.Vol. 6 No. 3.
| Statistical Recording|| |
Trachoma statistics are to be based on the incidence of the trachomatous patients and on the degree-sign of the trachoma intensity. Trachoma percentage of the conscripts is sufficiently competent to express the degree-sign.
Our (Rostkowski) works have demonstrated that trachoma degreesign is to be appreciated by the trachoma percentage of the conscripts as well as by the percentage of trachomatous patients among the patents with ocular afflictions. It has been proved that the percentage of the trachoma intensity degree among the conscripts is as much competent as the per cent of the trachomatous eyes among patients with eye diseases. It is - the exact percentage of trachomatons patients among the eye-afficted patients which is acknowledged as trachoma degree-sign of the population.
It is to be noted that the percentage of the trachoma-afflicted among the eye-afflcted is more or less 7 times greater than the trachoma degree-sign of the conscripts.
In the world medical literature and especially in "Revue du Trachoma" have appeared for years a number of works about the fight against trachoma ni different countries. It is felt that the matter is sufficiently ripe for us to compare the various methods and results of the measures taken in different countries
Finally the very interesting report of the Secretary of the Antitrachomatous Organization, Jean Sedan, is worth noting, where the author presents the results of the great work of "Revue Internationale du Trachoma" from 1924 to 1951, in a space of 13 years, founded in January 1924 by Victor Morax and Charles Nicolle to serve the action of the Organization against trachoma.
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