Mittal Ruchi, Balne Praveen K, Sahu Srikant, Das Sujata, Sharma Savitri
Dalmia Ophthalmic Pathology Services, L. V. Prasad Eye Institute, Bhubaneswar, Orissa, India.
Ocular Microbiology Services, L. V. Prasad Eye Institute, Bhubaneswar, Orissa; Jhaveri Microbiology Centre, L. V. Prasad Eye Institute, Hyderabad, Telangana, India.
Indian J Ophthalmol. 2017 Apr;65(4):276-281. doi: 10.4103/ijo.IJO_761_15.
Microsporidial stromal keratitis poses several diagnostic challenges. Patients may present with corneal ulceration, marked stromal thinning, or even as a quite corneal scar. The presentation of microsporidial stromal keratitis commonly mimics viral keratitis. Microbiology scrapings are usually helpful; however, scraping and culture-negative cases pose a significant diagnostic dilemma. Histopathological examination is diagnostic but shows varying degree of inflammation, predominantly composed of polymorphonuclear leukocytes. Granulomatous inflammation, in microsporidial stromal keratitis, is never well described, and the authors in this article aim to describe the presence of granulomatous inflammation in microsporidial stromal keratitis, in patients with associated herpes simplex virus (HSV) keratitis.
This was a retrospective and observational study conducted at a tertiary eye care center.
Of 263 patients who underwent therapeutic penetrating keratoplasty for infectious keratitis, during 2011-2013, seven patients were diagnosed as microsporidial stromal keratitis. Microsporidial spores could be demonstrated on microbiological scrapings in 5/7 (71%) of cases, but identified on histopathological examination and also confirmed on polymerase chain reaction (PCR) for microsporidium in 100% of cases. There was evidence of diffuse stromal necrosis with markedly severe degree of polymorphonuclear leukocytic infiltrates, with granulomatous inflammation in 42% of cases. Interestingly, these were positive for HSV-1 DNA on PCR. Review of medical records revealed much severe clinical presentations in patients with granulomatous inflammation, in comparison to cases without granulomatous inflammation.
The authors hereby recommend that severe clinical presentation in patients with microsporidial stromal keratitis, markedly dense polymorphonuclear leukocytic infiltrates or the presence of granulomatous inflammation on the histopathological examination, should be investigated further for the presence of HSV-1 DNA for better patient management and good visual outcome.
微孢子虫性基质性角膜炎带来了诸多诊断挑战。患者可能表现为角膜溃疡、明显的基质变薄，甚至是角膜瘢痕。微孢子虫性基质性角膜炎的表现通常类似病毒性角膜炎。微生物刮片通常很有帮助；然而，刮片及培养阴性的病例会带来重大的诊断难题。组织病理学检查具有诊断价值，但显示出不同程度的炎症，主要由多形核白细胞组成。微孢子虫性基质性角膜炎中的肉芽肿性炎症从未得到充分描述，本文作者旨在描述合并单纯疱疹病毒（HSV）角膜炎的患者微孢子虫性基质性角膜炎中肉芽肿性炎症的存在情况。
这是一项在三级眼科护理中心进行的回顾性观察研究。
在2011年至2013年期间接受治疗性穿透性角膜移植术治疗感染性角膜炎的263例患者中，7例被诊断为微孢子虫性基质性角膜炎。5/7（71%）的病例在微生物刮片中可发现微孢子虫孢子，但在组织病理学检查中均能识别，并且通过微孢子虫的聚合酶链反应（PCR）在100%的病例中得到证实。有证据表明存在弥漫性基质坏死，伴有明显严重程度的多形核白细胞浸润，42%的病例存在肉芽肿性炎症。有趣的是，这些病例的PCR检测显示HSV - 1 DNA呈阳性。病历回顾显示，与无肉芽肿性炎症的病例相比，有肉芽肿性炎症的患者临床表现更为严重。
作者特此建议，对于微孢子虫性基质性角膜炎患者，若临床表现严重、组织病理学检查显示明显密集的多形核白细胞浸润或存在肉芽肿性炎症，应进一步检测HSV - 1 DNA，以便更好地管理患者并获得良好的视觉效果。
