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| CASE REPORT |
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| Year : 1992 | Volume
: 40
| Issue : 4 | Page : 124-125 |
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Acanthamoeba keratitis-A report of two cases
T Girija, R Kumari, M Gurudath Kamath, Rama Ramani, Rama Mohan, PG Shivananda
Departmentss of Microbiology & Ophthalmology, Kasturba Medical College, Malipal, India
Correspondence Address:
P G Shivananda
Dept. of Microbiology, Kasturba Medical College, Manipal. 576 119, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 1300304 
Two cases of unilateral corneal ulcers caused by Acanthamoeba are reported. Neither of the patients had contact lenses at any time. The diagnosis was confirmed by Giemsa stain and cultures of the corneal scrapings.
How to cite this article:
Girija T, Kumari R, Kamath M G, Ramani R, Mohan R, Shivananda P G. Acanthamoeba keratitis-A report of two cases. Indian J Ophthalmol 1992;40:124-5 |
| Introduction | |  |
Acanthamoeba keratitis, a potentially devastating corneal infection through rare, is often associated with contact lens wear [1],[2],[3].Though there were a number of reports in the Western literature [4],[5],[6],[7]sub Sharma et al [8],[9] appear to be the first to report Acanthamoeba keratitis from India. We are reporting two such cases in patients who never had contact lenses.
| Case reports | | |
Case 1:
A 32 year old female was admitted in June, 1990 with pain, redness and defective vision in the right eye of 12 days duration. There was no history of trauma or foreign body falling into the eye. She never wore contact lenses but did apply some native drugs in this eye, which did not give her any relief. On examination, the lids were oedematous with narrowed palpebral aperture. There was circumcorneal congestion. On slit lamp examination, the cornea showed a stromal infiltration over an area of 10 mm diameter between 5 and 7 O'clock position. Corneal abscess was present. Anterior chamber was hazy with hypopyon. The visual acuity in the right eye was just perception of light. The lacrimal passages were clear. The left eye was normal. Repeated corneal ulcer scrapings were sterile both for bacteria and fungus. With a provisional diagnosis of corneal ulcer of right eye with posterior corneal abscess, she was treated with gentamycin and cephaloridine eye drops second hourly for two weeks. Her condition did not improve. In view of secondary glaucoma, paracentesis was done. At this stage, Giemsa stain of corneal ulcer scrapings and material aspirated from paracentesis showed polygonal double walled cysts of Acanthamoeba. Deep stromal scrapings from the edge of the corneal ulcer inoculated on non-nutrient agar with Escherichia coli overlay (0) grew Acanthamoeba in 48 hours.
However, no bacteria or fungus could be isolated from these materials. The patient was started on oral metronidazole (400 mg 8th hourly), oriprim eye drops (6th hourly), neosporin eye ointment (8th hourly) and diamox (250 mg, 6th hourly). Inspite of this treatment, the ulcer perforated and healed with an adherent leucoma formation.
CASE 2:
A 38 year old female was admitted in October, 1990 with pain, redness, watering and irritation of the left eye. She gave a history of paddy husk injury to the left eye 7 days prior to the development of these symptoms and also noticed a white spot in the left eye 4 days after the injury. On slit lamp examination, the left eye showed circumcorneal congestion with a central corneal ulcer of 1.6 x 1.4 mm size with clear margins extending into the superficial stroma. Anterior chamber was normal. There was no hypopyon. Lacrimal passages were free. Visual acuity in the right eye was 6/6 whereas in left eye it was 6/18. Multiple corneal ulcer scrapings stained with Giemsa stain showed cysts of Acanthamoeba which was confirmed by culture. No bacteria orfungi was isolated from these corneal ulcer scrapings.
The ulcer was treated two hourly with cephaloridine and gentamycin eye drops. As there was no improvement, a penetrating keratoplasty was done, following which the ulcer healed well to form a corneal opacity.
| Discussion | | |
Since 1974, when it was first described in a mat with ocular trauma, a number of reports mostly from the West, were published [4],[5],[6] on this subject.However, Sharma et al appear to be the first to report from India [8],[9].
Though most of these reports were in contact lens wearers [2],[3] neither of our patients had contact lenses at any time. One of our patient had exposure to organic material which may be the predisposing factor. Corneal trauma, dust and contaminated water were the other reported predisposing factors [10].
Keratitis is the commonest presentation. In some of these cases, a superadded bacterial infection may result in hypopyon as seen in our first case.
Most often, in these cases, bacterial and fungal infection is suspected and looked for; but not the Acanthamoeba infection. This, may be the reason for the low incidence of Acanthamoeba keratitis. However, an increased awareness is likely to improve the isolation of Acanthamoeba. The observation of cysts in Giemsa stain of the corneal ulcer scrapings was the hallmark of our diagnosis with subsequent positive cultures for Acanthamoeba.
The therapeutic strategy for Acanthamoeba keratitis is not yet established. Prolonged and intensive topical therapy with neomycin, polymyxin B, gramicidin, propamidine isothionate 0.1% and miconozole nitrate 1% and systemic metronidazole may be an effective mode of therapy for this condition [11]. Penetrating keratoplasty, done in our second case, is the surgical therapy for these cases [9].
From our experience, it appears that inspite of the best efforts, these ulcers heal with residual sequelae like corneal opacity, leucoma formation etc.
We conclude by saying that a high index of suspicion is necessary to diagnose Acanthamoeba infection. A routine Giemsa staining and culture for Acanthamoeba alongwith other cultures for bacteria and fungus will establish an early diagnosis.
| References | | |
| 1. | Lund, O.E., Stefani, F.H. and Dechant, W., Amoebic keratitis: a clinicopathological case report, Brit. J. Ophthalmol, 1970, 62, 373-375.  |
| 2. | Moore, M.B., McCulley, J.P., Luckenbach, M., Gelender, H. et. al., Acanthamoeba keratitis associated with soft contact lenses, Am.J. Ophthalmol, 1985, 100, 396-403. |
| 3. | John, T., Descu, B., and Sham, D., Adherence of Acanthamoeba Castellani cysts and trophozoites to unworn soft contact lenses. Am. J. Ophthalmol, 1989, 108, 6, 658-664. |
| 4. | M.P., Juechter,K., The sixth case of Acanthamoeba infection of the eye. Presented at the 79th Annual Meeting of the American Society of Microbiology, Los Angeles, May 4, 1979. |
| 5. | Key,S.N.,Green.W.R.,Willaert,E.,etal.,Keratitisdue to Acanthamoeba castellani: A clinicopathologic case report. Arch. Ophthalmol, 1980, 98, 475-479. |
| 6. | Simitzis Leflochic, A.M., Hasle, D.P., Paniague-Crespo,K., et al., Amoebic keratitis with Acanthamoeba. Epidemiological and parasitological study (Fren). J.Fr. Ophthalmol, 1989, 12, 5, 361-366. |
| 7. | Nagington, J., Watson, P.O., Playfair, T.G., McGill, J., Jones, BR, and Steele, A.D., Amoebic infection of the eye. Lancet, 1974, 2, 15-37. |
| 8. | Savitri, S., Srinivasan, M., George, C., Keratitis due to Acanthamoeba castellani, Afro-Asian J. Ophthalmol, 1988, VII (2), 104-106. |
| 9. | Savitri, S., Srinivasan, M., George, C., Diagnosis of Acanthamoeba keratitis-A report of four cases and review of literature, Ind. J. Ophthalmol, 1990, 38, 2, 50-56. |
| 10. | Jeanette, K., Stehr-Green, M.D., Theodore, M., Bailey, M.D. and Govinda, S., Visvesvara, The epidemiology of Acanthamoeba karatitis in the United States. Am. J. Ophthalmol, 1989, 107, 331-336. |
| 11. | Berger, S.T., Mondine, B.J., Haft, R.H., et,al., successful management of Acantharnoeba karatitis, Am. J. Ophthalmol, 1990, 110, 4, 395-403. |
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