Reactive arthritis: images.

Reactive arthritis is an extremely rare spondyloarthritis that affects the peripheral joints and spine, resulting in common symptoms such as arthritis, urethritis, conjunctivitis, and mucocutaneous lesions. On rare occasions, oral lesions such as circinate erosions on the hard and soft palate, gums, tongue, and cheeks may occur. Reactive arthritis may develop during or after genitourinary or gastrointestinal bacterial infections such as Shigella, Salmonella, Yersinia, and Chlamydia. A 36-year-old man presented with circinate balanitis, urethral discharge, oligoarthralgia, conjunctivitis, lymphadenopathy, pharyngitis, and erythematous lesions on the palate. Culture examination showed presence of Neisseria gonorrhoeae and antibiotic treatment resulted in improvement of conjunctivitis and the lesions on the penis. However, severe oligoarthralgia, palatal erosions that increased in severity and size, and depilated areas on the tongue were observed. The definitive diagnosis was reactive arthritis. The prevalence of sexually transmitted infections is increasing, highlighting the need to increase awareness of associated risks such as reactive arthritis. Moreover, consideration of non-specific oral manifestations in a systemic context may aid in effective diagnosis and treatment, suggesting the need for multidisciplinary teams.

Characterization of baseline polybacterial versus monobacterial infections in three randomized controlled bacterial conjunctivitis trials and microbial outcomes with besifloxacin ophthalmic suspension 0.6.

BACKGROUND/PURPOSE: To date, studies examining polymicrobial infections in ocular disease have mostly been limited to keratitis or endophthalmitis. We characterized polybacterial infections compared to monobacterial infections in prior clinical studies evaluating besifloxacin ophthalmic suspension 0.6% for the treatment of bacterial conjunctivitis and report on associated microbiological outcomes. METHODS: In this post-hoc analysis, microbiological data for subjects with conjunctivitis due to one or more than one bacterial species in three previous studies (two vehicle-, one active-controlled) of besifloxacin were extracted. Bacterial species identified at baseline were deemed causative if their colony count equaled or exceeded species-specific prespecified threshold criteria. In subjects with polybacterial infections, the fold-increase over threshold was used to rank order the contribution of individual species. Baseline pathogens and their minimum inhibitory concentrations (MICs) for common ophthalmic antibiotics were compared by infection type, as were microbial eradication rates following treatment with besifloxacin. RESULTS: Of 1041 subjects with culture-confirmed conjunctivitis, 17% had polybacterial and 83% had monobacterial conjunctivitis at baseline. In polybacterial compared to monobacterial infections, Haemophilus influenzae and Streptococcus pneumoniae were identified less frequently as the dominant infecting species (P = 0.042 and P<0.001, respectively), whereas Streptococcus mitis/S. mitis group was identified more frequently as dominant (P<0.001). Viral coinfection was also identified more frequently in polybacterial infections (P<0.001). Staphylococcus aureus was the most common coinfecting species in polybacterial infections and the second most common dominant species in such infections. With few exceptions, MICs for individual species were comparable regardless of infection type. Clinical microbial eradication rates with besifloxacin were high regardless of infection type (P≤0.016 vs vehicle at follow-up visits). CONCLUSIONS: Approximately one in five subjects with bacterial conjunctivitis are infected with more than one bacterial species underscoring the need for a broad-spectrum antibiotic for such infections. Besifloxacin treatment resulted in robust eradication rates of these infections comparable to monobacterial infections. TRIAL REGISTRATION: NCT000622908, NCT00347932, NCT00348348.

House finches with high coccidia burdens experience more severe experimental Mycoplasma gallisepticum infections.

Parasites co-infecting hosts can interact directly and indirectly to affect parasite growth and disease manifestation. We examined potential interactions between two common parasites of house finches: the bacterium Mycoplasma gallisepticum that causes conjunctivitis and the intestinal coccidian parasite Isospora sp. We quantified coccidia burdens prior to and following experimental infection with M. gallisepticum, exploiting the birds' range of natural coccidia burdens. Birds with greater baseline coccidia burdens developed higher M. gallisepticum loads and longer lasting conjunctivitis following inoculation. However, experimental inoculation with M. gallisepticum did not appear to alter coccidia shedding. Our study suggests that differences in immunocompetence or condition may predispose some finches to more severe infections with both pathogens.

Antibiotic resistance among bacterial conjunctival pathogens collected in the Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) surveillance study.

The Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) surveillance study evaluates in vitro antibiotic resistance among Staphylococcus aureus, coagulase-negative staphylococci (CoNS), Streptococcus pneumoniae, Pseudomonas aeruginosa, and Haemophilus influenzae isolates from ocular infections. Here we report resistance rates and trends among conjunctival-sourced ocular isolates collected across the US from 2009 through 2016. A total of 1198 conjunctival isolates (483 S. aureus, 305 CoNS, 208 H. influenzae, 118 S. pneumoniae, and 84 P. aeruginosa) were collected from patients with presumed bacterial conjunctivitis from 57 sites across 40 states. A large proportion of staphylococci demonstrated resistance to oxacillin and azithromycin, while resistance was low against the majority of antibiotics tested for S. pneumoniae, P. aeruginosa, and H. influenzae. Multidrug resistance (≥3 antibiotic classes) was found in 30.2% of S. aureus and 39.0% of CoNS isolates, and methicillin resistance more than doubled the rate of multi-drug resistance (methicillin-resistant S. aureus [MRSA], 76.5%; methicillin-resistant CoNS isolates, 72.8%). There was a pattern of increasing mean percent resistance with increasing age by decade of life among S. aureus, MRSA, and CoNS (P≤0.038). Over the eight-year study period, there were small yet significant decreases in resistance rates among S. aureus to azithromycin, ciprofloxacin, tobramycin, trimethoprim, and oxacillin (P≤0.003), and among CoNS and P. aeruginosa (both P<0.05) to ciprofloxacin. These data indicate that antibiotic resistance is high, but did not increase, among conjunctival-sourced isolates collected in the US from 2009 through 2016. For certain antibiotic/pathogen combinations, there was a trend of decreased resistance, including a decrease in oxacillin resistance among S. aureus.

Characterization of unilateral conjunctival inoculation with Mycoplasma gallisepticum in house finches.

House finches in much of the continental United States experience annual epidemics of mycoplasmal conjunctivitis, caused by the bacterial pathogen Mycoplasma gallisepticum (MG). Although evidence suggests that natural infections typically begin unilaterally, experimental inoculations of songbirds with MG to date have all been administered bilaterally. Furthermore, studies of free-living finches find more severe clinical signs of mycoplasmal conjunctivitis in left versus right eyes, but the mechanisms underlying this side bias remain unknown. Here, we characterized unilateral inoculation of house finches with MG, and tested whether differential susceptibility of left versus right conjunctiva explains the side bias in disease severity of free-living finches. We directly inoculated house finches in either the left or right conjunctiva and characterized resulting disease severity and pathogen load throughout the course of infection. As expected, unilateral inoculation resulted in significantly more severe conjunctivitis, as well as higher conjunctival bacterial loads, on whichever side (left or right) birds were directly inoculated. However, in 55% of cases, unilateral inoculations resulted in bilateral disease, and in 85% cases there was evidence of bilateral infection. The overall severity of disease did not differ for birds inoculated in the left versus right conjunctiva, suggesting that physiological differences between the conjunctivae cannot explain the side bias in disease severity of free-living birds. Instead, laterality in exposure, perhaps due to feeding handedness, likely explains the detected field patterns. RESEARCH HIGHLIGHTS House finches show more severe disease in the directly inoculated conjunctiva. Unilateral inoculations lead to high rates of bilateral infection and disease. Overall disease severity does not differ for the left- or right-inoculated conjunctiva. Laterality in exposure likely explains the left-side bias in natural infections.

Eyedrop Inoculation Causes Sublethal Leptospirosis in Mice.

Leptospirosis is potentially a fatal zoonosis acquired by contact of skin and mucosal surfaces with soil and water contaminated with infected urine. We analyzed the outcome of infection of C3H/HeJ mice with Leptospira interrogans serovar Copenhageni using an enzootic mode of transmission, the conjunctival route. Infection led to weight loss and L. interrogans dissemination from blood to urine, and spirochetes were detected in blood and urine simultaneously. The infectious dose that led to consistent dissemination to kidney after conjunctival infection was ∼108 leptospires. Interestingly, a lower number of spirochetes appeared to colonize the kidney, given that we quantified ∼105 and ∼10 leptospires per µl of urine and per µg of kidney, respectively. Leptospira-specific IgM and IgG were detected at 15 days postinfection, and isotyping of the Ig subclass showed that the total IgG response switched from an IgG1 response to an IgG3 response after infection with L. interrogans Histological periodic acid-Schiff D staining of infected kidney showed interstitial nephritis, mononuclear cell infiltrates, and reduced size of glomeruli. Quantification of proinflammatory immunomediators in kidney showed that keratinocyte-derived chemokine, macrophage inflammatory protein 2, RANTES, tumor necrosis factor alpha, gamma interferon, and interleukin-10 were upregulated in infected mice. We show that the kinetics of disease progression after infection via the ocular conjunctiva is delayed compared with infection via the standard intraperitoneal route. Differences may be related to the number of L. interrogans spirochetes that succeed in overcoming the natural defenses of the ocular conjunctiva and transit through tissue.

[Neonatal conjunctivitis in the district of Glidji in Southern Togo: a cross sectional study about 159 new-borns]. / Les conjonctivites néonatales dans le canton de Glidji au Sud du Togo: une étude transversale à propos de 159 nouveau-nés.

INTRODUCTION: Describe the epidemiology of neonatal conjunctivitis in the Canton of Glidji in southern Togo. METHODS: We conducted a cross-sectional study in 4 Satellite Health Care Units in the Canton of Glidji from 19 March to 13 May 2009 (8 weeks). All newborns were included in the study and neonatal conjunctivitis was defined by the presence in a newborn of at least two of the following signs: conjunctival hyperemia, eyelid swelling, chemosis, purulent discharges, lacrimation. The parameters studied were: age, sex, risk factors, medical history, presence or absence of conjunctivitis, germs responsible for conjunctivitis and evolution under treatment. RESULTS: During the inclusion period, 159 newborns were examined. The average age was 10.9 days with 0-28 day interval. The study involved 80 boys and 79 girls (sex ratio 1.01). Of the 159 infants, 7 cases of conjunctivitis were diagnosed, representing an overall prevalence of 4.4%. Identified risk factors were: vaginal delivery and the presence of STI during pregnancy. Of the 7 cases of conjunctivitis, cytobacteriological examination allowed the isolation of Staphylococcus aureus in 2 cases. The evolution of the cases of conjunctivitis under treatment was favorable with regression of the signs since the 3rd day. CONCLUSION: Neonatal conjunctivitis had a prevalence of 4.4% in the Canton of Glidji in southern Togo and Staphylococcus aureus was the causative germ. Their prevention requires good follow-up prenatal visit and the administration of antibiotic eye drops at birth.

Identification of causative pathogens in eyes with bacterial conjunctivitis by bacterial cell count and microbiota analysis.

PURPOSE: To determine the causative pathogens in eyes with bacterial conjunctivitis. DESIGN: Evaluation of diagnostic test or technology. PARTICIPANTS: Thirteen eyes diagnosed clinically with bacterial conjunctivitis and 12 eyes with normal conjunctival sac were studied. METHODS: The bacterial cell numbers were counted in the samples stained by ethidium bromide (EtBr). The microbiota was determined by the clone library method using polymerase chain reaction (PCR) amplification of the 16S ribosomal RNA (rRNA) gene with universal primers. In addition, examinations of smears and cultures of samples were performed. MAIN OUTCOME MEASURES: Bacterial cell numbers determined by the EtBr staining method and microbiota analysis based on 16S rRNA gene of samples from eyes with bacterial conjunctivitis. RESULTS: The bacterial cell numbers in the eyes with bacterial conjunctivitis were significantly higher than those in the normal conjunctival sacs. Ten of 13 samples from the eyes with bacterial conjunctivitis had positive PCR results. The remaining 3 samples and all 12 samples from the normal conjunctiva had negative PCR results. In 5 of the 10 PCR-positive samples, the predominant species accounted for 84.5% or more of each clone library. In the remaining 5 samples, the predominant and the second dominant species accounted for 27.4% to 56.3% and 19.0% to 26.8%, respectively, of each clone library. The number of detected species in the clone libraries was between 8 and 20 (average ± standard deviation, 7.5 ± 5.8). Bacteria were detected in 8 of the 10 bacterial conjunctivitis samples and in 5 of the 12 normal samples in the cultures. The number of species detected by cultures was 1 in the eyes with bacterial conjunctivitis and between 1 and 3 (mean ± standard deviation, 1.6 ± 0.9) in the normal conjunctiva. CONCLUSIONS: These results showed that the bacterial cell number in a sample is a good method of determining bacterial conjunctivitis. The microbiota analysis detected a diverse group of microbiota in the eyes with bacterial conjunctivitis and showed that the causative pathogens could be determined based on percentages of bacterial species in the clone libraries. The combination of bacterial cell count and microbiota analysis is a good method for identifying the causative pathogens in cases of monomicrobial and polymicrobial conjunctivitis.

Lacrimal gland ductulitis caused by probable Actinomyces infection.

OBJECTIVE: To describe the clinical characteristics and management of a group of patients who had chronic mucopurulent conjunctivitis that was probably due to Actinomyces infection of the lacrimal gland ductules. DESIGN: A retrospective, interventional case series. PARTICIPANTS: Seven patients (2 male; 29%) between 34 and 52 years of age (mean, 48.7 years; median, 49 years) who presented to the lacrimal clinic. INTERVENTION: Surgical excision of the infective focus (6 cases) or fenestration and expression of infective debris (1 case) from the affected lacrimal gland ductule--typically the most inferolateral of the ductules. MAIN OUTCOME MEASURES: The clinical features of this previously unrecognized cause of chronic conjunctivitis and its response to treatment. RESULTS: All cases settled rapidly after surgery. There was often a major delay in diagnosis, with the patients having symptoms for between 2 and 42 months before referral (mean, 13.3 months; median, 9 months); 5 patients received prolonged or ineffectual topical medical therapy before referral. CONCLUSIONS: Infective lacrimal gland ductulitis, commonly from Actinomyces infection, should be considered in patients with unexplained chronic mucopurulent conjunctivitis; the condition settles rapidly with surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Pathogenicity and immunogenicity of three Mycoplasma gallisepticum isolates in house finches (Carpodacus mexicanus).

Mycoplasma gallisepticum (MG) has become a common cause of conjunctivitis in free-living house finches (Carpodacus mexicanus) since its emergence in the early 1990s. To date, temporal and spatial genotypic variation in MG has been documented, but phenotypic variation in pathogenicity and immunogenicity has not been examined. House finches were inoculated with MG isolates Virginia (VA)1994, California (CA)2006, or North Carolina (NC)2006, which were cultured from free-living house finches with conjunctivitis in 1994, 2006, and 2006, respectively. Infection with NC2006 resulted in the most severe eye lesions, highest pathogen loads, and highest levels of pathogen-specific lachrymal and serum antibodies. Infection with CA2006 caused the least severe eye lesions, lowest pathogen load, and lowest levels of antibodies. A small number of birds in each group developed protracted, severe disease in spite of robust antibody responses, suggesting that immunopathology may contribute to the lesions. Immunoblot analyses indicated that isolates are antigenically similar; thus, there may be partial cross-protection if a house finch encounters two or more strains of MG throughout the course of its lifetime. This study provides evidence that MG strains or strain variants circulating in house finch populations vary in their ability to cause disease, induce antibody responses, and persist in the host.

Assessment of Streptococcus pneumoniae capsule in conjunctivitis and keratitis in vivo neuraminidase activity increases in nonencapsulated pneumococci following conjunctival infection.

PURPOSE: The pneumococcal capsule is required for pathogenesis in systemic infections, yet reports show most conjunctivitis outbreaks are caused by nonencapsulated pneumococci, while keratitis infections are caused by encapsulated strains. This study aims to determine the effect of capsule in pneumococcal keratitis and conjunctivitis in rabbit models of infection. METHODS: A capsule-deficient isogenic mutant was created using homologous transformation. Parent and mutant strains were injected within the upper bulbar conjunctiva (conjunctivitis) or into the corneal stroma (keratitis) of New Zealand white rabbits. Clinical examinations were performed 24 and 48 hr post-infection at which time corneas or conjunctivae were removed, homogenized, and plated to determine the recovered bacterial load. Whole eyes were removed for histological examination. The neuraminidase activity was determined following in vitro and in vivo growth. RESULTS: There were no significant differences in clinical scores between the eyes infected with the parent or mutant for either infection, nor was there a difference in the amount of bacteria recovered from the cornea. In the conjunctivae, however, the mutant strain was cleared by the host faster than the parent strain. Histological examination showed slightly more infiltrating polymorphonuclear leukocytes (PMN) and macrophages in the conjunctivae infected with the parent strain. The neuraminidase activity of both strains was not significantly different when the strains were grown in vitro. However, the neuraminidase activity of the parent was significantly less than that of the mutant at 3 and 12 hr post conjunctival infection. CONCLUSIONS: Although more outbreaks of pneumococcal conjunctivitis are tied to nonencapsulated S. pneumoniae strains, this study showed that an encapsulated strain was capable of establishing conjunctivitis in a rabbit injection model and survive attack by the host immune system longer than its nonencapsulated isogenic mutant. Nonetheless, the nonencapsulated pneumococci had an increased neuraminidase activity level in vivo when compared to the parent strain.

Oculoglandular syndrome caused by Yersinia pseudotuberculosis in a dairy goat.

An outbreak of ocular disease in a herd of housed dairy goats was characterized by severe granulomatous conjunctivitis and ipsilateral parotid and submandibular lymphadenopathy. In one case submitted for post-mortem examination, Yersinia pseudotuberculosis was isolated from both the conjunctiva and submandibular lymph node. Histopathological examination identified severe chronic active suppurative and lymphoplasmacytic conjunctivitis and suppurative and necrotizing lymphadenitis associated with bacteria of yersinial morphology. Similar pathological changes occur in Parinaud's oculoglandular syndrome in man due to infection with Y. pseudotuberculosis.