Presentación atípica de molusco contagioso: compromiso ocular bilateral en paciente con VIH / Atypical presentation of molluscum contagiosum: bilateral ocular involvement in a patient with HIV

La infección por molusco contagioso (MC) en adultos se asocia frecuentemente a transmisión sexual y/o inmunodepresión, por ejemplo, por VIH. En este grupo, la manifestación clínica suele ser atípica. A continuación, se presenta el caso de un paciente con diagnóstico de VIH, bajo recuento de CD4 y carga viral elevada que consulta por múltiples MC en genitales, tronco, cara y ojos además de conjuntivitis en ojo derecho. Se mantuvo terapia antirretroviral (TARV) y se indicó tratamiento para conjuntivitis. La infección por MC en pacientes con VIH se asocia a etapas SIDA con un aumento de los casos a menor recuento de linfocitos CD4, generalmente menor a 200 cel/mL. La pobre respuesta inmune celular de estos pacientes explica su comportamiento clínico atípico. Este grupo presenta una mayor mortalidad que el de pacientes seropositivos sin MC, lo que se explica por la mayor inmunosupresión asociada. El diagnóstico es clínico, aunque podría verse entorpecido cuando hay compromiso ocular por la presencia de lesiones atípicas que hacen necesario considerar diversos diagnósticos diferenciales. El tratamiento es controversial y tiende a existir una baja respuesta y recidiva frente a terapias convencionales en pacientes con VIH cuando la inmunosupresión es marcada por el recuento CD4 muy bajo. La TARV pareciera ser la mejor alternativa para su tratamiento, sin embargo, es importante considerar posibles complicaciones asociadas, como la instauración de síndrome de restauración inmunológica una vez iniciada. Esto podría traducirse en lesiones oculares graves cuando existe compromiso en este órgano

Molluscum contagiosum (MC) infection in adults is frequently associated with sexual transmission and / or immunosuppression, for example by HIV. In this group, the clinical manifestation is usually atypical. Herein we present the case of a patient with a diagnosis of HIV, a low CD4 count and a high viral load who consulted for multiple MC in the genitals, trunk, face and eyes, as well as conjunctivitis in the right eye. Antiretrovitral therapy (ART) was maintained and treatment for conjunctivitis was indicated. MC infection in HIV patients is associated with AIDS stages with an increase in cases with a lower CD4 lymphocyte count, generally less than 200 cells / mL. The poor cellular immune response of these patients explains their atypical clinical behavior. This group presents a higher mortality than that of seropositive patients without MC, which is explained by the greater associated immunosuppression. The diagnosis is clinical, although it could be hampered when there is ocular compromise due to the presence of atypical lesions that make it necessary to consider various differential diagnoses. Treatment is controversial and there tends to be a poor response and relapse to conventional therapies in patients with HIV when immunosuppression is marked by a very low CD4 count. ART seems to be the best alternative for its. However, it is important to consider possible associated complications such as the onset of immune restoration syndrome once it has been started. This could translate into serious eye injuries when this organ is compromised

Correlation between clinical signs of feline conjunctivitis and molecular detection of felid herpesvirus-1, feline calicivirus, chlamydophila felis and mycoplasma felis in cats from shelters in Rio de Janeiro / Correlação entre sinais clínicos da conjuntivite felina e a detecção molecular de felid herpesvirus-1, feline calicivirus, chlamydophila felis e mycoplasma felis em gatos de abrigos no Rio de Janeiro

Objectives: To perform molecular diagnosis of microbial agents (FHV-1, FCV, Mycoplasma felis, and Chlamydophila felis) in kittens with conjunctivitis and correlate the clinical signs with clinical severity. Material and Methods: A total of 108 conjunctival swab were collected from kittens without (G1; n = 40) and with (G2; n = 68) clinical signs of conjunctivitis. Animals from G2 group were scored from 1 (mild) to 4 (severe) according to the severity of conjunctivitis. All samples were submitted to PCR and RT-PCR. Results: FHV-1 was detected in 62/108 (57.4%) of samples, FCV in 40/108 (37.0%), M. felis in 11/108 (10.2%) and C. felis in 26/108 (24.1%). Mixed infections were detected in 39/108 (36.1%). In G1, 28/40 (70.0%) were positive for one or more agents, in G2, 58/68 (85.3%) were positive (P = 0.03). In 1, single infections by FHV-1were found in 21/40 (52.5%) samples, FCV in 2/40 (5.0%), C. felis in 1/40 (2.5%), and no pathogens were detected in 12/40 (30%) of samples, while mixed infections accounted for 29/40 (72.5%) of the cases. In G2, single FHV-1 infections were found in 31/68 (45.6%) samples, FCV in 10/68 (14.7 %), M. felis in 2/68 (3.0%) and C. felis also in 2/68 (3.0%), and no pathogens were detected in 10/68 (14.7%) samples, while mixed infections accounted for 36/68 (52.0%) of the cases. They were categorized as grade 1, 20/68 (29.4%), grade 2, 14/68 (20.6%), grade 3, 21/68 (30.9%) and grade 4, 13/68 (19.1%). The presence of FHV-1 and FCV is equally distributed among the four categories. More severe clinical signs, scores 3 and 4, are related to coinfections by C. felis and M. felis. Conclusions: FHV-1, FCV, C. felis and M. felis were identified in feline conjunctivitis. Co-infections are related to more severe cases of conjunctivitis.Molecular diagnosis is helpful to detect asymptomatic carriers and is a rapid and accurate method to determine the pathogen of feline conjunctivitis.(AU)

O objetivo deste estudo foi realizar diagnóstico molecular de agentes microbiológicos (FHV-1, FCV, Mycoplasma felis e Chlamydophila felis) em gatos filhotes e associar a presença dos patógenos à gravidade dos sinais clínicos de conjuntivite. Foram coletadas um total de 108 amostras de suabe conjuntival de filhotes felinos assintomáticos (G1; n = 40) e sintomáticos (G2; n = 68). Animais do G2 foram categorizados de 1 (leve) até 4 (grave), de acordo com o quadro clínico de conjuntivite. As 108 amostras foram submetidas à PCR e RT-PCR. O FHV-1 foi detectado em 57,4% das amostras, o FCV em 37%, o M. felis em 10,2% e o C. felis em 24,1%. Coinfecções, por sua vez, foram detectadas em 36,1%. No G1, 70% das amostras foram positivas para um ou mais patógenos. No G2, 85,3% apresentavam infecções (P = 0,03). No G1, monoinfecções por FHV-1 foram diagnosticadas em 52,5% das amostras, por FCV em 5%, por C. felis em 2,5%, e em 30% das amostras analisadas nenhum dos patógenos estudados foi encontrado. Coinfecções, por sua vez, estavam presentes em 72,5% das amostras. No G2, monoinfecções por FHV-1 foram encontradas em 45,6% das amostras, por FCV em 14,7 %, por M. felis em 3% e por C. felis também em 3%. Nenhum dos patógenos estudados foi encontrado em 14,7% das amostras analisadas. Coinfecções, responsáveis por 52% dos casos, foram categorizados como Grau 1 (29,4%), Grau 2 (20,6%), Grau 3 (30,9%) e Grau 4 (19,1%). A presença de FHV-1 e FCV está igualmente distribuída entre as quatro categorias. Os sinais clínicos mais graves (graus 3 e 4) estão relacionados a coinfecções por C. felis e M. felis. Os agentes microbiológicos FHV-1, FCV, C. felis e M. felis foram encontrados em animais com conjuntivite. Coinfecções estão relacionadas aos casos mais graves. Por fim, concluiu-se que o diagnóstico molecular, além de detectar portadores assintomáticos, é um método rápido e acurado para o diagnóstico do patógeno causador da conjuntivite felina.(AU)

Prevalência de conjuntivite adenoviral em clínica oftalmológica no município de Viçosa (MG) / Prevalence of adenoviral conjunctivitis at the ophthalmologic clinic on municipality of Viçosa/MG

Objetivo: Avaliar a prevalência de Adenovírus como agente etiológico da conjuntivite, em clínica médica oftalmológica especializada, em Viçosa, Minas Gerais, Brasil. Métodos: Amostras da secreção conjuntival de 91 pacientes clinicamente diagnosticados com conjuntivite foram submetidos à reação em cadeia da polimerase (PCR), utilizando primers degenerados para a região codificadora do gene da proteína estrutural II. Posteriormente as amostras positivas foram submetidas a sequenciamento e genotipagem. Resultados: A análise dos resultados de PCR revelou prevalência de 36,3% de Adenovírus. Não havendo distinção entre os sexos e com maior prevalência na faixa etária de 26 a 65 anos com 60,60% dos casos positivos. O sequenciamento dos casos positivos por Adenovírus revelaram a presença dos sorotipos 3, 4, 7, 8 e 34 circulante na região. Conclusão: No município de Viçosa, dois em cada cinco casos de conjuntivite são de etiologia adenoviral.

Objective: The aim of this study was to evaluate the prevalence of Adenovirus as a etiologic agent of conjunctivitis on a ophthalmic clinic in Viçosa, Minas Gerais, Brazil. Methods: Samples of conjunctival secretion from 91 patients clinically diagnosed with conjunctivitis were subjected to polymerase chain reaction (PCR) using degenerate primers targeted to the gene encoding the structural protein II. Positive samples were subsequently subjected to sequencing and genotyping. Results: PCR results showed 36.3% prevalence of Adenovirus. No differences between the sexes and was found to be higher in the age group 26-65 years with 60.60% of the positive cases. Sequencing of positive cases showed the presence of Adenovirus serotypes 3, 4, 7, 8, and 34 circulating in the region. Conclusion: In Viçosa two in five cases of conjunctivitis has Adenovirus as etiologic agent.

Uso de ganciclovir 0,15 por cento gel para tratamento de ceratoconjuntivite adenoviral / Ganciclovir 0.15 percent ophthalmic gel in the treatment of adenovirus keratoconjuntivitis

OBJETIVOS: Determinar a efetividade e a toxicidade do ganciclovir 0,15 por cento gel no tratamento de ceratoconjuntivites adenovirais e na prevenção de complicações tais como infiltrados corneanos, membranas ou pseudomembranas conjuntivais. MÉTODOS: Ensaio clínico duplo-cego, intervencionista, randomizado. Os 33 pacientes com diagnóstico clínico de ceratoconjuntivite adenoviral com início dos sintomas há menos de cinco dias foram randomizados em dois grupos: Grupo 1 (tratamento) com 19 pacientes que usaram ganciclovir e Grupo 2 (controle) com 14 pacientes que usaram lágrima artificial sem conservante. Todos pacientes responderam a um questionário de sinais e sintomas e foram submetidos a um exame oftalmológico. No 6º dia de tratamento responderam ao mesmo questionário por telefone e no 10º dia foram reavaliados pelo mesmo examinador e responderam novamente ao questionário. Os sinais e sintomas foram comparados. Para análise estatística foi utilizado os testes T de Student, Mann-Whitney e Wilcoxon, com significância estatística p<0,05. RESULTADOS: Tendência de melhor resposta no grupo tratamento em relação à percepção pelos pacientes, além da melhora mais rápida desse grupo em relação ao grupo controle (p=0,26). Houve menor transmissão para o olho adelfo (p=0,86) e para pessoas do convívio (p=0,16) no grupo tratamento. Comparando os dois grupos não houve diferença estatística em relação aos sintomas e sinais da conjuntivite. Comparando isoladamente cada grupo entre o pré-tratamento e no decorrer do tratamento, observou-se melhora estatisticamente significativa da dor, prurido e fotofobia apenas no grupo tratamento. Ganciclovir não mostrou toxicidade e teve maior tolerância pelos pacientes. Não houve diferença significativa no aparecimento de complicações da conjuntivite entre os dois grupos. CONCLUSÕES: O estudo evidenciou uma tendência à melhora mais rápida dos sinais e sintomas dos pacientes tratados com ganciclovir em relação ao grupo ...

PURPOSE: To evaluate the efficacy and the toxicity of 0.15 percent ganciclovir gel in the treatment of adenoviral conjunctivitis and in preventing ocular complications after adenoviral conjunctivitis, such as corneal infiltrates and pseudomembranes. METHODS: Double blind, interventional and randomized clinical trial. Thirty-three patients with clinical diagnosis of adenoviral conjunctivitis with onset of symptoms for five or less days were randomized in two groups: Group 1 (treatment) with 19 patients used ganciclovir gel and Group 2 (control) with 14 patients used artificial tears without preservative. Patients answered a questionnaire of signs and symptoms and were submitted to an ophthalmologic exam. On the 6th and 10th days of treatment they answered the same questions and were re-examined by the same ophthalmologist. Signs and symptoms were compared. T Student, Mann-Whitney e Wilcoxon tests were used to statistical analysis. RESULTS: Trend of better response in the treatment group in relation of patients' perception, besides faster improvement of this group compared to the control group (p=0.26). There were lower transmission to the fellow eye (p=0.86) and to people living together (p=0.16) in the treatment group. No statistical difference related to signs and symptoms of conjunctivitis were found comparing both groups. We observed statistical difference in pain, itch and photophobia only in the treatment group, comparing each group alone. No toxicity and more tolerance of the ganciclovir were observed. There was no statistical difference in the ocular complications after conjunctivitis between both groups. CONCLUSIONS: This study showed trend of better and faster response of the signs and symptoms of the patients treated with ganciclovir compared with the control group, but with no statistical significant. These results need to be confirmed by additional studies, with more patients and longer follow-up. Clinical Trails.gov: NCT01349452.

Development of EKC after Eximer Laser Photorefractive Surgery and Subsequent Recurrence of EKC-like Keratitis

This research focuses on four cases of patients having undergone eximer laser photorefractive surgery who were diagnosed with adenoviral keratoconjunctivitis during the postoperative period and who later developed epidemic keratoconjunctivitis (EKC)-like keratitis. Two of the patients had undergone laser-assisted subepithelial keratectomy (LASEK), one had undergone laser in situ keratomileusis and one had photorefractive keratectomy. After the surgery adenoviral keratoconjunctivitis and recurrent late-developing EKC-like keratitis were observed in the patients. Recurrent late-developing EKC-like keratitis occurred in one of the patients, who had received LASEK as many as three times. The others had only one or two episodes.The corneal infiltrates of keratitis mainly occurred in the central cornea. Successful resolution of recurrent late-developing EKC-like keratitis was achieved through the use of topical steroids without sequelae and the final best-corrected visual acuity was as good as the base line. These keratitis infiltrates have been presumed to represent an immune response to the suspected adenoviral antigens deposited in corneal stroma during the primary adenoviral infection. Previous reports argued that patients with a history of adenoviral ketatoconjunctivitis were succeptible to adenoviral keratoconjunctivitis becoming reactivated; however, in our research, our patients had their first adenoviral infections after the eximer laser photorefractive surgery and reactivation was confirmed. We recommend that attention be paid to adenoviral infection after laser refractive operations, because these patients seem to have more frequent recurrences.

Curso de atualização em emergências médicas: aula 9: conjuntivites infecciosas agudas / Updating medical emergencies course: class 9: acute infectious conjunctivitis

Conjuntivite é todo processo inflamatório que envolve a membrana conjuntiva, independente da causa. A hiperemia conjuntival é um achado clínico sempre presente, podendo estar associado à secreção. Entretanto, a maior parte dos sinais clínicos só pode ser bem identificada com auxílio da microscopia clínica. Pode ser causada por agentes bacterianos ou virais, mas também por irritantes químicos como medicamentos, filtros solares e cremes faciais.

Conjunctivitis is an inflammatory disease affecting conjunctive membrane, independet of etiology. Conjunctival hyperemia is always present and might come together with ophthalmic discharge. Nevertheless, the majority of clinical signs can only be recognized using microscopy. The acute disease may be due to bacterial or viral infection. Other causes include chemical irritants as drugs, suscreen of facial lotion.

Diagnóstico de conjuntivite adenoviral pelo RPS Adenodetector® / Adenovirus conjunctivitis diagnosis using RPS Adenodetector®

OBJETIVO: Avaliar a utilização do RPS Adenodetector®, como método diagnóstico de pacientes com quadro clínico de conjuntivite adenoviral. MÉTODOS: Análise de série de casos consecutivos de pacientes com diagnóstico clínico de ceratoconjuntivite adenoviral submetidos comparativamente ao teste RPS Adenodetector® e a raspado conjuntival para cultura de vírus. RESULTADOS: Dos 11 pacientes avaliados, 10 pacientes apresentavam acometimento unilateral. Em relação ao tempo de início dos sintomas no momento da colheita, 5 (45,5 por cento) pacientes apresentavam dois dias de história, 5 (45,5 por cento) apresentavam três dias e 1 (9,1 por cento) apresentava 7 dias. A cultura para adenovírus foi positiva em 8 pacientes (73 por cento) e o RPS Adenodetector® foi positivo em 9 pacientes (82 por cento). Oito pacientes apresentaram o teste rápido e cultura positiva. Um paciente apresentou teste RPS Adenodetector® positivo com cultura negativa. Os dois pacientes com teste RPS Adenodetector® negativo apresentaram cultura negativa. O RPS Adenodetector® mostrou sensibilidade de 100 por cento e especificidade de 67 por cento adotando-se a cultura de vírus como exame padrão-ouro para o diagnóstico de conjuntivite adenoviral. CONCLUSÃO: O RPS Adenodetector® foi útil para o diagnóstico de conjuntivite adenoviral e pode auxiliar na orientação do paciente quanto ao contágio e disseminação da doença.

PURPOSE: To evaluate the RPS Adenodetector®, a rapid immunochromatographic test, in the diagnosis of patients with clinical overt adenoviral conjunctivitis. METHODS: Consecutive case series. Patients underwent conjunctiva scraping for RPS Adenodetector® test and culture to identify adenovirus. RESULTS: A total of 11 patients were studied, and 10 had unilateral disease. Five (45.5 percent) had symptoms for 2 days, 5 for three days, and 1 for 7 days. Adenovirus culture was positive in 8 patients (73 percent) and RPS Adenodetector® was positive in 9 (82 percent) patients. Eight patients had adenovirus identification by both methods. In one patient the RPS Adenodetector® was positive in contrast to a negative culture. The two patients revealing negative RPS Adenodetector® results also had negative cultures. The sensitivity was 100 percent and the specificity was 67 percent. CONCLUSION: The RPS Adenodetector® is a useful tool in the rapid diagnosis of adenovirus conjunctivitis and may contribute to the spread control of this highly contagious disease.

Laboratory investigations on viral and Chlamydia trachomatis infections of the eye: Sankara Nethralaya experiences.

PURPOSE: To review our experiences on the laboratory investigations of viral and chlamydial conjunctivitis, congenital cataract and acute retinal inflammations seen from 1990 to 1998 at Sankara Nethralaya, Chennai, India. METHODS: Conjunctival swabs/scrapings from 1061 patients with conjunctivitis were investigated. Nested polymerase chain reaction (nPCR) and restriction fragment length polymorphism (RFLP) techniques were applied on 74 conjunctival swabs during the 1996 outbreak of acute viral conjunctivitis. The occurrence of Rubella virus in 86 lens aspirates of congenital cataract was investigated. Tests were performed for the association of Herpes simplex virus (HSV), Varicella zoster virus (VZV) and Cytomegalovirus (CMV) with acute retinal inflammation in 32 patients. RESULTS: The causative agents of conjunctivitis were Adenovirus in 13.8%, HSV in 2.2% and C. trachomatis in 20.9% of the patients. Epidemics were due to Adenovirus type 4 in 1991, type 3 in 1992-93 and type 7a in 1996. PCR was 37.9% more sensitive in detecting Adenovirus than virological methods. RFLP identified the conjunctivitis epidemic strain of 1996 as Adenovirus 7a. Rubella virus was isolated from 8.1% of lens aspirates from congenital cataract. Nineteen of the 32 patients with acute retinitis had confirmed virus infections (VZV: 8; HSV: 5; and CMV: 6) and the rapid detection of the virus agent helped institute specific chemotherapy resulting in useful vision in some patients. CONCLUSION: Laboratory investigations for diagnosis of viral and C. trachomatis ocular infections were useful in establishing the aetiology and determining the incidence of causative agents of specific ocular diseases.

Conjuntivitis por adenovirus en niños / Conjuntivitis by adenovirus in children

Para establecer frecuencia del adenovirus (ADV) en niños con conjuntivitis, comparar técnicas de diagnóstico y características clínicas, se efectuó un estudio prospectivo desde julio de 1991 a enero de 1993 que incluyó 115 pacientes de 0 a 15 años, 44 hospitalizados y 71 ambulatorios. Se investigó ADV mediante inmunofluorescencia (IFI) y aislamiento viral (AV) en una muestra de epitelio conjuntival. Los resultados indicaron: 1) la prevalencia de ADV en conjuntivitis fue 48,7 por ciento; 2) los casos positivos se concentraron en niños menores de 5 años, hospitalizados y con compromiso respiratorio; 3) la presencia de pseudomembranas y edema palpebral fueron los únicos rasgos clínicos significativos para la presencia de ADV; 4) al comparar la IFI con el AV como técnica de diagnóstico, ésta resultó muy superior a la primera

Cytological evaluation of conjunctival scrape smears in cases of conjunctivitis.

The present study was conducted on 130 cases of untreated conjunctivitis and 25 control cases to assess the diagnostic value of cytology. Conjunctival scrapings from all cases were stained with Giemsa and Papanicoloau's stain and categorized cytologically and later correlated with the clinical profile. Normal cytologic profile was obtained in 7 cases (5.4%) of the study group and 14 cases (56%) of the control group. Cytologic diagnosis of trachoma was made in 63 cases (48.5%) including 48 out of 51 clinically diagnosed cases of trachoma, 9 cases of allergic conjunctivitis and 6 cases of acute follicular conjunctivitis, positive clinico cytologic correlation being 76.2%. Mucopurulent conjunctivitis was diagnosed in 24 cases (18.5%) both clinically as well as by cytological technique. Viral conjunctivitis was diagnosed in 24 cases (18.5%) including 19 cases (14.6%) of clinically diagnosed viral conjunctivitis and 5 cases (3.9%) of acute follicular conjunctivitis, positive correlation being 79.2%. Only 2 cases (1.5%) out of 15 clinically diagnosed cases of allergic conjunctivitis were confirmed cytologically. In all the 4 cases (3.1%) of spring catarrh and 6 cases (4.6%) of phlyctenular conjunctivitis the cytologic features were found to be consistent with the clinical diagnosis.

Ojo rojo / Red eye

Se señala que existen 2 variedades de ojo rojo, de los cuales uno es debido a inyección conjuntival y corresponde a los diversos tipos de conjuntivitis (bacterianas, virales y alérgicas) y el otro a la inyección ciliar o periquerática, propia de las afecciones de la córnea y del iris así como del glaucoma agudo. Desde el punto de vista de manejo y conducta, si el paciente presenta una clara inyección conjuntival con secreción y sin dolor, puede ser tratado por un médico general o un pediatra. Por el contrario, si el ojo rojo se debe a un halo violáceo que rodea la cornea y el diagnóstico no aparece claro, el paciente debe ser referido de inmediato al oftalmólogo ya que un mal manejo puede exponerlo a la pérdida de la visión