|Year : 1980 | Volume
| Issue : 3 | Page : 157-159
Actinomycotic lacrirnal canaliculitis
TA Joseph1, CKJ Paniker2, Saila Kumari1, Maheswari Amma2, KC Joseph1
1 Department of Ophthalmology, Medical College, Calicut, India
2 Department of Microbiology, Medical College, Calicut, India
T A Joseph
Department of Ophthalmology Medical College Hospital, Calicut-673 008
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Joseph T A, Paniker C, Kumari S, Amma M, Joseph K C. Actinomycotic lacrirnal canaliculitis. Indian J Ophthalmol 1980;28:157-9
Actinomyces is a genus of anaerobic microaerophilic non-acid fast organism within the family of Actinomycetaceae. The species pathogenic in man is usually Actinomyces Israelii.
A primary infection of the canaliculus is uncommon, but does occasionally occur Bacteria, fungi and virus produce such an infection of the lacrimal canaliculi, but the most common agent is fungal agent, reportedly Actinomyces Israelii. Since Streptothrix applies only to a developmental stage of the anaerobic Actinomyces Israelii, it should be abandoned.
A diagnosis based only on the gram-staining of the expressed material from the canaliculi may be misleading, as some may turn out to be Fusobacterium on appropriate culture,. So appropriate culture of the concretions expressed from the canaliculus is made before making a final diagnosis of Actinomyces Israelii.
| Case report|| |
A 70 year old Muslim woman was complaining of 2 year history of discharge from left eye and pain in the medial part of the left lower eye lid. She had been treated medically, with antibiotic ointments and drops, for the past two years elsewhere, without any improvement. Her general health was good on her initial visit. She lives in a rural area, but is neither an agriculture worker nor has had any close association with animals.
Initial examination revealed an uncorrected visual acuity of 6/9 both eyes. There was swelling of the medial 1/3 of the left inferior eye lid and the neighbouring part of the conjunctiva was inflammed. The left lower punctum was prominent [Figure - 1]. On pressure over the sac, yellowish pus regurgitated through the left lower punctum. On syringing the left lower punctum, resistance was felt and fluid regurgitated.
A dacryocystorhinostomy operation on left side was done. Post-operative period was uneventful. After 2 weeks, patient was relieved of symptoms and discharged. Again after 2 months the patient came with discharge from left eye, swelling of the medial 1/3 of left lower eye lid and redness of the neighbouring parts of conjunctiva. The left lower punctum was pouting. Syringing of the left lower punctum showed blockage and the fluid regurgitated. On 2nd Aug. 1979, the left inferior canaliculus was surgically slit and granulations and concretions evacuated and sent for bacteriological examination. The canaliculus was cauterized by iodine. Post-operatively antibiotic drops were applied. Two weeks post-operatively the wound had healed well and the patient was asymptomatic. All medications were stopped and she continued to do well.
Laboratory Studies Material obtained for microscopy and culture contained a large granule. A portion of the granule was used for microscopical examination and the remaining for culture. A portion of the granule crushed under the cover-slip in KOH revealed compact masses composed of delicate branching and intertwined filaments. The ends of these filaments seen around the periphery of granules had club-shaped appearance characteristic of Actinomycotic granule.
Another portion of the granule was crushed and -round. The smears taken from this ground material were gram-stained and examined under microscope, which showed gram positive short and long delicate and branched filaments [Figure - 2].
The ground material was inoculated into thioglycolate broth and brain-heart-infusion (B.H.1) agar. In thioglycolate broth, the growth appeared as white granular forms which later on settled to the bottom of the tubes.
BHI agar inoculated with the material was incubated anaerobically at 37. C. In about 2 days growth appeared as minute spidery colonies with branched mycelia, radiating from a central point. It grew into a smooth shiny molar-tooth like colonies within one week.
Smears taken from the growth on thioglycolate broth and BHI agar, stained by grams method showed gram positive branching filaments with fragment.
Since the cultures were contaminated with bacteria, physiologic tests were not carried out.
Based on the types of granules and morphology of the colonies isolated. it was identified as Actinomyces Israelii.
| Discussion|| |
Actinomycoses is one of the commonest mycoses in man, characterised by granulation and suppuration. Actinomyces Israelii is primarily a commensal found in normal oral cavities, in tonsillar crypts, in dental plaques, in carious teeth etc. Occasionally it becomes pathogenic in man. The distribution of actinomycosis in man is
(1) Cervicofacial 60%
(2) Ileocaecal region and Appendix 20%
(3) Lungs 15%
(4) Skin 5%
The method of infection is uncertain.
There is no evidence that it is conveyed directly from animals to man but is much commoner in farmers and other country dwellers The source of Actinomyces infection virtually in all cases is considered to be endogenous.
Actinomycosis can affect canaliculi, Lacrimal gland, lid-margins, Lids, and orbit. Among the primary ocular-Actinomycoses, Actinomycosis canaliculi is commonest. Its incidence varies geographically and while Wissman from Breslaw, considered that it formed 2% of all lacrimal disease, its occurrence is probably much less in other area In our hospital this is the first-case.
Recovery of concretions from an infected canaliculus has been taken for to be diagnostic of Actinomycosis. The so called sulfur granules, composed of aggregates of filamentous branching micro-organisms, classically associate d with Actinomycoses, are not always present in the Actinomyces infection. Other bacteria, such as staphylococcus aureus can form similar granules.
Even though Actinomyces is sensitive to penicillin, cure of the canaliculitis will not be effected, until all the concretions and granulations that were present in the canaliculus is meticulously removed.
| Summary|| |
A primary infection of the lacrimal canaliculus is relatively uncommon. In our hospital this is the first case reported. Mycotic infection should always be suspected in every case of unexplained persistent weeping.
| References|| |
Robert Cruickshank, 1965, Medical Microbiology, 11th Edition, P-305, E & S Livingstone, Great Britain.
Hubert, Me Culloch, Schnurrenberger, Disease Transmitted from Animals to Man, 6th Edition, P-361, Charles. C. Thomas, U.S.A.
Sorssby A. 1972, Modern Ophthalmology, 11th. Edition, P-877, Butterworth & Co., London.
Duke-Elder, Stewart. 1955, System of Ophthalmology, 1st Edition, P-5297, Kimpton, London.
Year Book of Ophathlmology, 1962-63, P-42, Year Book Medical Publisher, Chicago.
Weinberg Richar. A., Sartoris Marla. J., Buerger George F., and Novak Joseph. F., 1977, Amer J. Ophthalmol, 84, P-371.
Boyd, William 1977, Text Book of Pathology, 8th Edition, P-401, Lea & Febiger, Philadelphia.
Pine Leo, Hardin, H., and Turner, L., 1960, Amer J. of Ophthalmol, 49, P-1278.
Hogan and Zimmerman, 1962, Ophthalmic Pathology, 2nd Edition, P-224, U.S.A.
[Figure - 1], [Figure - 2]