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| ORIGINAL ARTICLE |
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| Year : 1982 | Volume
: 30
| Issue : 1 | Page : 37-41 |
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Chlamydial uveitis
PN Dhingra, LP Agarwal, VM Mahajan
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
Correspondence Address:
V M Mahajan
R. P. Centre A.I.I.M.S. New Delhi-110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 6890528 
How to cite this article:
Dhingra P N, Agarwal L P, Mahajan V M. Chlamydial uveitis. Indian J Ophthalmol 1982;30:37-41 |
The role of chlamydiae in human disease is being increasingly recognised. Recent studies have shown that Chlamydia trachomatis may cause systemic infection, i.e. pneumonitis in infants[1], pelvic inflammatory disease [2],[3], peritonitis and peri-hepatitis[4], so much so that trachoma has been hypothesized as an ocular component of a more generalised chlamydial infection[5]. Beyond conjunctiva and cornea, the evidence for involvement of other ocular structures is scanty. Though it has been possible to experimentally produce uveal lesions in rabbits and monkeys[6],[7] by inoculating chlamydia into the anterior chamber, clinical reports are not many. The report of juxtapapillary choroiditis in a twenty-one year old girl with rising anti-chlamydial antibody titre appears to be a reasonably convincing proof of expanding ocular pathogenicity spectrum of chlamydia.[8] We report here the isolation of chlamydia from the aqueous humour of a patient suffering from sub-acute granulomatous anterior uveitis and an attempt in reproducing nearly similar disease by directly inoculating the strain into the anterior chamber of a rhesus monkey and electron microscopic demonstration of chlamydial bodies in iris and ciliary body.
| Materials and methods | |  |
Aqueous humour samples : Nineteen samples were collected from clinically diagnosed patients of uveitis. Soon after aspiration, the sample was put into the transport medium[9].
Isolation of Chlamydia : Seven days old embryonating eggs were inoculated through the yolk sac route[10]. The specificity of mortality of the embryos was confirmed by demonstrating chlamydia in the yolk sac membranes both by immunofluorescence and by Gimenez stain.
Characterisation of chlamydia :
Characterisation of the strain was done according to the method of Storz[11].
1) By demonstrating regular mortality of the embryos with consistent demonstration of elementary bodies in yolk sac smears by immunofluorescence.
2) By producing follicular conjunctivitis in a rhesus monkey, 2-4 weeks after inoculating the strain over the scarified conjunctiva. Specificity was determined by re-isolating chlamydia, by demonstrating chlamydia in conjunctival epithelial cells by immunofluorescent staining and by demonstration of rising anti-chlamydial antibody titre as detected by complement fixation test (CFT)[12]
Inoculation into the anterior chamber of a monkey : Freshly harvested infected yolk sac membranes were emulsified in sucrose potassium glutamate (SPG) medium to make 40% suspension. After two cycles of low speed centrifugation, the partially purified suspension was centrifuged at 10,000 r.p.m. for 60 minutes at 4°C. The pellet was homogenised in one tenth of its original volume. After another centrifugation at 1000 r.p.m., the supernate was recentrifuged at 10,000 r.p.m. for 1 hour at 4°C. The resulting pellet was reconstituted in SPG medium. It was titrated in embryonating eggs and ELD 50 was calculated. Control inoculum was prepared similarly from un-infected yolk sac membranes.
A rhesus monkey, clinically free from any eye infection and serologically negative for (1, 1, rrydial group antibodies was anaesthetised and with a tuberculin syringe and 26 gauge needle, 0.2 ml aqueous humour was withdrawn. Exactly the same amount of inoculum (containing 10[4],[5] ELD 50) was inoculated into the right eye. Control inoculum was similarly inoculated into the left eye.
The monkey was clinically observed daily upto the 11th day when both the eyes were enucleated. The aqueous was drawn on 6th & 11th postinoculation days and examined for bacteria. The iris, ciliary body and cornea from the test and the control eyes were subjected to histopathology. Iris and ciliary body tissues from infected and the control eye were fixed in buffer and post-fixed in P /0 osmium tetroxide buffer. Ultra sections were stained with lead hydroxide73 and examined under electron microscope (Philips-300 model).
| Observations | | |
Out of nineteen samples, one chlamydial isolate was obtained. These samples were also inoculated in IUDR treated McCoy cells, but did not yield chlamydia for want of foetal calf serum. The strain killed the embryos between 7th and 9th post-inoculation day from 2nd passage onwards. Yolk sac smears were positive for elementary bodies of chlamydia. The isolate besides regularly killing the embryos, also produced follicular conjunctivitis in monkeys, the specificity of which was ascertained by re-isolation of chlamydia, demonstration of chlamydia in infected epithelial cells by Giemsa and fluorescent antibody technique, and by rising antibody titre (1:32) after 2-4 weeks of infection.
Clinical : After inoculating the purified chlamydial suspension into the. anterior chamber of the monkey, iritis of + + severity was discernible on the 2nd day. From the 3rd to 6th day, the anterior chamber appeared full of exudate [Figure - 1]. Hypopyon started resolving from 10th day; however, lid oedema, chemosis and haziness of the cornea still persisted [Figure - 2]. The control eye was normal within 72 hours.
Histopathology : Sections of the cornea showed atrophic epithelium and mild to moderate neutrophilic infiltration of the stroma. The stroma in addition, showed prominent keratocytes with a few vascular channels. Descemet's membrane was folded and showed focal detachment from the stroma. The endothelium was invisible. The segments of iris and ciliary body showed dense inflammatory exudate overlying its surface which consisted of degenerating mass. The stroma showed diffuse round cell infiltration with a few polymorphs [Figure - 3]. There was focal condensation of pigment on the posterior surface. The control tissues were normal.
Electron microscopy Each of the five sections of ciliary body and iris revealed the presence of chlamydiae in different developmental stages [Figure - 4][Figure - 5].
| Discussion | | |
The problem of recurrences in trachoma in endemic countries like India is still menacing. The question of whether reinfection occurs with a fresh strain or by recrudescence of an old dying infection, still remains unresolved. An experimental study conducted by us earlier[14] indicated that chlamydial activity was perceptible in the conjunctival tissue and the lacrimal apparatus till the 90th postinoculation day following a single conjunctival inoculation of Bour Strain of Chlamydia trachomatis in rhesus monkeys. Further, it was suggested that iridocyclitis especially in post-operative cases should be thoroughly investigated for chlamydia.
Sero-evidence of such infections suggested that 7% cases of uveitis could have been due to chlamydia. Since single serum sample studies are of little diagnostic value, we contemplated isolation of chlamydia from aqueous humour of uveitis patients. Out of nineteen samples processed in embryonating eggs, one chlamydial isolate was recovered which had all the classical features of chlamydia. Experimentally the pathogenicity of the strain for monkey conjunctiva was substantiated by re-isolation of chlamydia, cytology, demonstration of antigen in conjunctival scrapings by fluorescent antibody technique and by rising anti-chlamydial antibody tits e. The human patient (17 years old female) whose sample yielded this strain had conjunctival congestion, palpebral scarring and recent history of otitis media. Should this isolate be regarded as etiological agent of uveitis in the absence of overt trachoma or should it be regarded as derived from latent sub-clinical infection which persisted and was held in check by the host's defence mechanisms ? In an endemic country like India where inapparent or sub-clinical infections should be expected to occur in alarming numbers, chlamydial etiology of uveitis in this case is probable especially in the presence of clinical, micro-biological and experimental proofs.
Upon inoculating the purified yolk sac suspension of chlamydia into the antes for chamber of the monkey, severe iritis developed in 48 hours followed by marked hypopyon so much so that comments on aqueous flare could not be made. Pupil was not visible. The exudates started resolving from 10th day onwards. Control eye inoculated with un-infected yolk sac membrane suspension became normal by the 3rd day of inoculation. The aqueous samples drawn on 6th and 11th post-inoculation days were negative for bacteria both by direct examination and by culture. These, however, showed 3-5 polymorphs per high power field of the microscope. In the 11th day specimen, mononuclear cells replaced the polymorphs. In fact, aspiration of aqueous was difficult all through and therefore, the isolation of chlamydia was not possible.
Histopathology of cornea showed a mild to moderate neutrophilic infiltration of the stroma whereas the iris and ciliary body were infiltrated with mononuclear cells. These findings are inconformity with those of Oh and Tarizzo[6] and Mohan et a1[7]. Inclusion bodies could not be seen in any of the tissues. However, electron microscopy revealed intermediate developmental stages (giant bodies and initial bodies) of chlamydia in iris stroma and ciliary body. This confirms that the lesions were actually caused by chlamydia. It is imminent that uvea though initially suffers from acute inflammatory reaction does not suffer long. This happens even in conjunctival lesions, perhaps a characteristic feature of chlamydial infections. Had we followed this animal further, the role of iris as a carrier tissue, fate of chlamydia and course of the disease could have been better studied. However, it may be recommended that chlamydial aetiology of uveitis especially in trachoma endemic countries should be duly considered.
| Summary | | |
An isolation of Chlamydia trachomatis from the aqueous humour of a patient suffering from sub-acute granulomatous anterior uveitis has been reported. The strain produced severe iritis when inoculated into the anterior chamber of Indian Rhesus monkey Histopathology revealed the involvement of cornea, iris and the ciliary body. Chlamydiae have been demonstrated in different developmental stages in the ciliary body and the iris by electron microscopy. Chlamydial etiology of uveitis especially in trachoma endemic countries should be considered.
| References | | |
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| 2. | Mardh, P.A., Ripa, K.T., Svensson, L. and Westrom, L., 1977, New Eng. J. Med. 297:1377. |
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| 4. | Muller-Shoop, J.W. ; Wang, S.P. : Munzinger, J. ; Schlapfer, H.U., Knobbanch, M. and Anmanu, R.W., 19 78., Brit. Med. J. I: 1022. |
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| 9. | WHO, 197.;., Guide to the laboratory diagnosis of trachoma. Geneva. |
| 10. | Mahajan, V.M., Balaya, S., Mohapatra, L. N. and Agarwal, L.P., 1977. East Arch. Ophthalmol. 5 : 52. |
| 11. | It. Storz, J., 1971. Chlamydia and chlamydia induced diseases. Springfield, Illionis,, C.C. Thomas. |
| 12. | Lennette, E.H. and Schmidt, N.J., 1969., Diagnostic procedures for viral and rickettsial infections. 5th Ed. New York. Amer. Pub. Hith. Assoc. |
| 13. | Millioning, G., 1961 ; J. Biophys. Biochem. Cvtol. 11 :736. |
| 14. | Mahajan. V.M. ; Niroola, R. and Agarwal, L.P.,1979, East. Arch. Ophthalmol. 7 : 1. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
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