|Year : 1970 | Volume
| Issue : 2 | Page : 82-85
A case of infective granuloma of eye led causing spontaneous perforation of the lid
B. S. Medical College, Bankura, (W. B.), India
B. S. Medical College, Bankura, (W. B.)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Basu A. A case of infective granuloma of eye led causing spontaneous perforation of the lid. Indian J Ophthalmol 1970;18:82-5
| Introduction|| |
Body  describes granulomata as a variety of chronic inflammation characterised by lesions which tend to be distinctly circumscribed and by cells rather of histiocytic than of haematogenous type. Granulomatous inflammation is a highly specific reaction of the reticulo-endothelial system. The cells of this system have a great ability to change their form, to proliferate and to move through the tissues. The result is a granuloma.
Granulomas may be divided according to the causal agent into (1). Infective and foreign body granulomas. The infective granulomas in turn may be due to (i) bacteria, (ii) fungi, or (iii) viruses. In addition there are a few examples of unknown aetiology, of which the best are Sarcoidosis and Regional ileitis.
A girl "Khuki Ruidas", aged 3½, yrs., was admitted on 17.1.69 in the eye wards of the B. S. Medical College Hospital with a large oedematous swelling of the left upper eye lid, extending upto the cheek, temple and forehead of the left side. On examination - a semi solid growth of about 1" by ½" was seen arising from the under surface of the left upper eye lid. The growth was sessile, skin over the lid was red and tender to touch. Preauricular gland was palpable on left side, but not enlarged nor tender. Temperature was 101°F. Nothing abnormal was detected in the other eye.
General condition - The girl was very ill, weak and very much emaciated.
History of onset - The mother of the girl said that about 7 days back she noticed one small pimple over the left upper eye lid near the eye brow. She applied some mustard oil over it and suddenly it developed into the present condition.
| Treatment|| |
1. Inj. Cryst. Penicillin 22 ½ lakhs intramuscularly twice a day.
2. Inj. Streptomycin 0.25 gm. daily intramuscularly.
3. Inj. Vit. C 500 mgm. daily intramuscularly.
4. Lykacline (Tetracycline) Eyeointment 4 times daily in the left eye.
Next day (18.1.69) her blood was sent for total and differential count (as there was no visible vein, only slides were drawn and approximate results found), which were: W. B. C. 15000. Neutro. 40%, LymphD. 54%, Eosin 2%, Mono. 4%. For the same reason blood for sedimentation rate and V. D. R. L. could not be drawn. Mantoux test 1 in 10,000 was negative. Her mother's blood was sent for V. D. R. L. which was negative.
On 20.1.69: general condition fair, pulse 120 p.m., temp. 98.4° F, the condition of the swelling was almost the same.
As the swelling did not come down and the girl was suffering, Inj. Penicillin and Streptomycin were replaced by Inj. Terramycin 25 mgm. 6 hourly intramuscularly and along with it the following treatment was advised:
1. Becadex (Vit. B complex) 12 drops B.D. (orally)
2. Mist. ferri et ammon. cit. 2 drams, twice a day (orally).
3. Mag. sulph compress over the swelling.
4. Lykaclin eye ointment to apply locally.
On 21.1.69 the swelling subsided a little.
On 23.1.69 the left upper lid had sloughed out at the centre, through which the growth could be seen as evideuced by the photograph taken on the next day (24.1.69). (Plate 1)
On 30.1.69 - when the general condition of the child improved a little so that the child could stand general anaesthesia, an operation was undertaken A growth, 1" by ½" was removed from the under surface of the left upper lid and the sloughed portion stitched up. The mass was sent to the pathology department and for histo - pathological examination. The report was:- "Section shows extensive areas of necrosis with granulation tissue and heavy infiltrate of Mono - nuclear cells." (Plate 2) The pathological diagnosis was of an Infective granuloma.
On the second dressing (after 4 days) the stitches spontaneously gave way and there was contracture of the lid causing its eversion and gradually within a few days, a typical cicatrical cctropion developed.
On 17.2.69 - under G. A. - Tarsorrhaphy was done in the left eye, fibrous tissue bands dissected, skin mobilised, bare area covered with mobilised skin and the skin stitched up. After 10 days Tarsorrhaphy was released and the stitches removed. The recovery was uneventful regarding healing of the wound, but there was slight shortening of the width of the lid exposing about 2½ mm of the lower part of the left eye ball on closing the lid. As the patient was very anxious to go home she was discharged from the hospital with the advice of coming at a later date for a plastic operation of the lid.
| Discussion|| |
Duke Elder classifies granulomas of the lid as:
1. Non-Specific granuloma
2. Staphylococcal granuloma
(a) Telangiectatic granuloma (granuloma pyogenicum)
3. Granuloma Venereum (Inguinale)
4. Coccidioidal granuloma
5. Para coccidioidal granuloma
6. Granuloma fungoides.
In differentiating the granulomas - foreign body granulomas are diagnosed histologically by the demonstration of a foreign body in the tissue, usually clustered around by very large foreign body giant cells with numerous nuclei scattered throughout the cytoplasm lacking the peripheral or polar arrangement seen in the Langham's type.
Of the infective granulomas - in syphilis, plasma cells and lymphocytes may preponderate, but by and large histiocyte is the characteristic cell. It is well seen in tuberculosis, but in its purest form in Sarcoidosis. Necrosis and actual caseation of the central part of the lesion may occur, usually in tuberculosis, almost never in sarcoido sis. Granuloma of the lid due to Bru. cellosis is very very rare.
Under mycotic granulomas come Actinomycosis, Blastomyces, Sporotricosis, Coccidiomyces and Histoplasmosis. Of these Actinomycosis is common in lids and it is characterised by an acute exudative element.
The only virus granuloma is Lymphogranuloma Venereum.
Telangiectatic granuloma or granuloma pyogenicum is a fairly common tumour arising from the skin or mucous membrane as a result of trauma, irritation or of reaction to the presence of pyogenic bacteria, and the eye lid is a common location, particularly the lid margin. It bleeds profusely, painless but tender. The usual infective agent is Staphylo aureus.
Botroymycosis is common in horses, exceedingly rare in man, caused by Staphylcocci.
Granuloma Venereum (Inguinale) is quite seperate from lymphogranuloma venereum which is caused by a virus. The infection is common among Negroes in U.S.A. and West Indies but a rare incidental invader of Great Britain and Western Europe. It is a venereal disease affecting both sexes, characterised initally by the appearance of a red papule on the skin which progresses to a chronic granulomatous ulceration without adenopathy.
Coccidioidal granuloma is caused by infection of Coccidioides immitis and is somewhat rare in the lids. It occurs typically in California, Texas and Mexico. Cutaneous lesions have been reported from Japan. Initial cutaneous lesion is a dusky, red nodule which ulcerates and exudes pus rich in fungus, eventually developes into an ulcerating and purulent granulomatous mass.
Paracoccidioidal granuloma is caused by the fungus Paracoccidioides brasiliensis, occuring particularly in Brazil, being of vegetable origin. The lesion starts as a furuncle which ulcerates, becomes verrucose and pustulates.
Granuloma funguides is characterised by a somewhat indefinite histological picture of histiocytes, myelocytes and plasmocytes supported by a reticular scaffolding; the cellular picture may closely resemble Hodgekin's disease, Lymphoma or Leucaemia. It commences typically as a chronic eczematous dermatitis, the numerous circinate patches may last for years.
Non-specific granulomata are small rapidly growing inflammatory pseudo-tumours usually attaining the size of a pea, somewhat soft in consistency and frequently associated with considerable swelling of the lid. The skin over the tumour is normal and no tenderness is present. Histologically, they are madeup of dense connective tissue infiltrated especially in the peri vascular areas with lymphocytes and occasional plasma cells. Frequently giant cells indicate that the tumour is in reality a tissue defence against a foreign body.
The histological and clinical picture of the case clearly points out to the diagnosis of an Infective Granuloma.
| Summary|| |
A case of swelling of left upper eye lid in a female child was admitted in the eye indoor of the B. S. Medical College Hospital.
There was a growth on the inner surface of the left upper lid which ultimately perforated the lid.
The growth was removed and found to be an infective granuloma.
The lid was repaired.
| References|| |
Boyd Willium: A text book of Pathology, 7th edition, 1962, page 61, Lea & Febiger, Philadelphia.
Duke Elder Stewart: Text book of Ophthalmology, Vol. V, 1952, Henry Kimpton, London.
Sorsby Arnold: Systemic Ophthalmology, 2nd edition, 1958, page 559, Butterworth & Co. (publishers) Ltd., London.
[Figure - 1], [Figure - 2]