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Leptotrichosis of the Conjunctiva
LEPTOTRICHOSIS OP T H E CONJUNCTIVA. EDWIN BLAKESLEE D U N P H Y ,
M.D.
BOSTON, MASS.
Two cases of "Parinaud's Conjunctivitis," occurred in a brother and sister. T h e lesions were typical, and contained the leptothrix described by Verhoeff. The patients had been in close contact with a cat that had sore ears. Both patients recovered.
Leptotrichosis Conjunctivae, or Parinaud's Conjunctivitis, is a subacute inflammatory process of the conjunc tiva due to infection by a leptothrix. It is characterized by enlargement of the preauricular gland. Very often other nearby glands are also involved. The conjunctival lesions consist of small grayish areas 1/2 mm. to 4 mm. in diameter, situated just beneath the epithelium. These areas are infiltrated with endothelial phagocytes undergo ing necrosis and contain the leptothrix in large numbers. Beneath these areas there is a formation of granulation tis sue causing polypoid projections of the conjunctiva. The disease was first described clin ically by Parinaud in 1889. No histologic study was made and it was not until 1904, when Verhoeff and Derby 1 reported a case, that certain distinctive histologic features were described by Verhoeff. . Bernheimer 2 in 1906 con firmed these observations. In 1913 VerhoefP reported a series of twelve cases and discovery of the organism. In 1918 he4 added six more cases and published a resume of the eighteen cases he had studied. The leptothrix had been found in all the cases except one, where there was insufficient ma terial saved. Animal inoculations and cultures were unsuccessful whenever tried. In 1924 Lemoine 5 reported a case in which he found the conjunc tival lesions and organisms described by Verhoeff. In Verhoeff's series the average age was eighteen years. Males predomi nated over females in the ratio of 14:4. The seasonal incidence was interesting, thirteen cases out of a total of eighteen occurring in the months of November, December, and January. Altho cases did occur in the summer, it was dis tinctly a cold weather disease. A his tory of slight trauma was obtained in four cases. In three cases there was history of animal contact, but in every 669
case the animal in question was free from any known disease. The disease was always unilateral and in no in stance was a case known to have been associated in any way with another case of the disease. The following two cases are reported because: (1) They are the first in stance, I believe, of two cases occur ring in the same family at the same time, the patients being brother and sister. (2) There was definite history of contact with a diseased animal. Case I. Harold M., age 14, was first seen by me on December 24, 1925. Two weeks previously he had received a slight cut at the outer canthus of the left eye from the sharp edge of a paper being drawn across his face. Three days later he noticed that the left eye felt sore and irritated. There was slight mucoid discharge. At the same time he noticed a painless swelling in front of the left ear. Treatment at home consisted of boric acid wash. The gland became larger and some what tender. Examination showed the lower lid swollen and edematous, with slight mucopurulent discharge. From the fornix below there protruded a rather large nodule of conjunctiva, containing a yellow gray top. The rest of the fornix was edematous and showed some follicle formation. On the upper lid were several polypoid granulations. The bulbar conjunctiva was injected only at the lower temporal portion. The cornea was clear. Vision was 6/6. There was marked enlargement and slight tenderness of the preauricular and anterior cervical glands on the same side. Smear of conjunctival secretion was entirely negative. Con stitutional symptoms were lacking. A diagnosis of Parinaud's conjunctivitis was made and the patient taken to Dr. Verhoeff's laboratory for excision and study of the nodule in the lower fornix. Dr. Verhoeff reported the typical his tologic picture with leptothrices present in large numbers.
670
LEPTOTRICHOSIS OF CONJUNCTIVA
The only local treatment given was a zinc sulphate solution, 1/4 gr. to a 1/2 ounce of water every three hours. There was a rapid recovery and at date of present writing (six weeks from on set of disease) the lids present an en tirely normal appearance, but there is still marked swelling of preauricular and other regional glands. Case II. Dorothea M., age 12, seen the same time as her brother. Four days previously the left eye felt sore and the upper lid became swollen. Next day a swelling was noticed in front of the left ear. There was a slight mucoid discharge from the eye. Boric acid washes did not improve the' condition. There were no constitu tional symptoms. Examination showed an inflamed edematous upper lid at outer canthus, similar to a beginning hordeolum but no tender point could be elicited. There was moderate enlargement of the pre auricular gland. Upon everting the upper lid, there were seen several tabs of conjunctiva 2-3 mm. in length all along the lid. Near the outer canthus were two small, white, elevated areas about 1 to 2 mm. in diameter, bathed in mucopurulent secretion. The con junctiva near the outer canthus was edematous back to the fornix. The bulbar conjunctiva was only slightly injected above. The cornea was clear. Vision was 6/6 both eyes. Smear of conjunctival secretion showed nothing of importance. The small white ele vated areas were excised and prepared by Dr. Verhoeff. Numerous leptothrices were found with the typical histologic picture of Parinaud's con junctivitis. This case was put on mercurochrome, 1% solution every three hours, and made an uneventful recovery. At the present time (five weeks after on set) there remains only a slight injec tion of the conjunctiva in the upper lid,
and a slight enlargement of the pre auricular gland. About two weeks before the onset of the disease in the boy, a cat had been taken into the household. It was noticed by the family that the animal had a small sore in each ear. In spite of this, the cat was quite a constant companion of the children, often sleep ing in the bed with one or the other of them. This cat was brought to the laboratory and examined by Dr. Ver hoeff and myself with the hope of find ing leptothrices in the lesion, but un fortunately the sore ears were already healed and there was no tissue avail able for biopsy. A study of these two cases brings up the question as to direct transmission from one individual to another, and also the possibility, after all, of animal contact being an important considera tion. Experimentally the disease has ap parently been transmitted from man to animal by Wherry and Ray 6 . They report a supposed case of Parinaud's conjunctivitis in which pus aspirated from the preauricular gland was inocu lated subcutaneously into a white mouse, producing an infection charac terized by purulent conjunctivitis and death. Postmortem there was isolated from muscular abscesses a leptothrix, which grew only on egg medium, in cubator under partial tension and ana erobic condition. In the same human case the organism was successfully cultured directly from pus of the gland. Unfortunately the conjunctival lesions of the patient were not examined histologically, so that it remains uncer tain whether or not the case was actu ally one of Parinaud's conjunctivitis, and whether or not the organism was the same as that found by Verhoeff in the conjunctival lesions of his cases. 520 Commonwealth Ave.
REFERENCES.
1. Verhoeff and Derby. Arch, of Ophth., 1904, vol. XXXIII, p. 389. 2. Bernheimer. Klin. Monat. f. Augenh., 1906, vol. XLIV, p. 323. 3. Verhoeff. Arch, of Ophth., 1913, vol. XLIII, p. 345. 4. Verhoeff. Amer. Jour, of Ophth., October, 1918. 5. Lemoine. Jour. Amer. Med. Assn., 1924, vol. LXXXII, p. 537. 6. Wherry and Ray. Journ. Infectious Diseases, 1918, vol. XXII, p. 554.
M.D.
BOSTON, MASS.
Two cases of "Parinaud's Conjunctivitis," occurred in a brother and sister. T h e lesions were typical, and contained the leptothrix described by Verhoeff. The patients had been in close contact with a cat that had sore ears. Both patients recovered.
Leptotrichosis Conjunctivae, or Parinaud's Conjunctivitis, is a subacute inflammatory process of the conjunc tiva due to infection by a leptothrix. It is characterized by enlargement of the preauricular gland. Very often other nearby glands are also involved. The conjunctival lesions consist of small grayish areas 1/2 mm. to 4 mm. in diameter, situated just beneath the epithelium. These areas are infiltrated with endothelial phagocytes undergo ing necrosis and contain the leptothrix in large numbers. Beneath these areas there is a formation of granulation tis sue causing polypoid projections of the conjunctiva. The disease was first described clin ically by Parinaud in 1889. No histologic study was made and it was not until 1904, when Verhoeff and Derby 1 reported a case, that certain distinctive histologic features were described by Verhoeff. . Bernheimer 2 in 1906 con firmed these observations. In 1913 VerhoefP reported a series of twelve cases and discovery of the organism. In 1918 he4 added six more cases and published a resume of the eighteen cases he had studied. The leptothrix had been found in all the cases except one, where there was insufficient ma terial saved. Animal inoculations and cultures were unsuccessful whenever tried. In 1924 Lemoine 5 reported a case in which he found the conjunc tival lesions and organisms described by Verhoeff. In Verhoeff's series the average age was eighteen years. Males predomi nated over females in the ratio of 14:4. The seasonal incidence was interesting, thirteen cases out of a total of eighteen occurring in the months of November, December, and January. Altho cases did occur in the summer, it was dis tinctly a cold weather disease. A his tory of slight trauma was obtained in four cases. In three cases there was history of animal contact, but in every 669
case the animal in question was free from any known disease. The disease was always unilateral and in no in stance was a case known to have been associated in any way with another case of the disease. The following two cases are reported because: (1) They are the first in stance, I believe, of two cases occur ring in the same family at the same time, the patients being brother and sister. (2) There was definite history of contact with a diseased animal. Case I. Harold M., age 14, was first seen by me on December 24, 1925. Two weeks previously he had received a slight cut at the outer canthus of the left eye from the sharp edge of a paper being drawn across his face. Three days later he noticed that the left eye felt sore and irritated. There was slight mucoid discharge. At the same time he noticed a painless swelling in front of the left ear. Treatment at home consisted of boric acid wash. The gland became larger and some what tender. Examination showed the lower lid swollen and edematous, with slight mucopurulent discharge. From the fornix below there protruded a rather large nodule of conjunctiva, containing a yellow gray top. The rest of the fornix was edematous and showed some follicle formation. On the upper lid were several polypoid granulations. The bulbar conjunctiva was injected only at the lower temporal portion. The cornea was clear. Vision was 6/6. There was marked enlargement and slight tenderness of the preauricular and anterior cervical glands on the same side. Smear of conjunctival secretion was entirely negative. Con stitutional symptoms were lacking. A diagnosis of Parinaud's conjunctivitis was made and the patient taken to Dr. Verhoeff's laboratory for excision and study of the nodule in the lower fornix. Dr. Verhoeff reported the typical his tologic picture with leptothrices present in large numbers.
670
LEPTOTRICHOSIS OF CONJUNCTIVA
The only local treatment given was a zinc sulphate solution, 1/4 gr. to a 1/2 ounce of water every three hours. There was a rapid recovery and at date of present writing (six weeks from on set of disease) the lids present an en tirely normal appearance, but there is still marked swelling of preauricular and other regional glands. Case II. Dorothea M., age 12, seen the same time as her brother. Four days previously the left eye felt sore and the upper lid became swollen. Next day a swelling was noticed in front of the left ear. There was a slight mucoid discharge from the eye. Boric acid washes did not improve the' condition. There were no constitu tional symptoms. Examination showed an inflamed edematous upper lid at outer canthus, similar to a beginning hordeolum but no tender point could be elicited. There was moderate enlargement of the pre auricular gland. Upon everting the upper lid, there were seen several tabs of conjunctiva 2-3 mm. in length all along the lid. Near the outer canthus were two small, white, elevated areas about 1 to 2 mm. in diameter, bathed in mucopurulent secretion. The con junctiva near the outer canthus was edematous back to the fornix. The bulbar conjunctiva was only slightly injected above. The cornea was clear. Vision was 6/6 both eyes. Smear of conjunctival secretion showed nothing of importance. The small white ele vated areas were excised and prepared by Dr. Verhoeff. Numerous leptothrices were found with the typical histologic picture of Parinaud's con junctivitis. This case was put on mercurochrome, 1% solution every three hours, and made an uneventful recovery. At the present time (five weeks after on set) there remains only a slight injec tion of the conjunctiva in the upper lid,
and a slight enlargement of the pre auricular gland. About two weeks before the onset of the disease in the boy, a cat had been taken into the household. It was noticed by the family that the animal had a small sore in each ear. In spite of this, the cat was quite a constant companion of the children, often sleep ing in the bed with one or the other of them. This cat was brought to the laboratory and examined by Dr. Ver hoeff and myself with the hope of find ing leptothrices in the lesion, but un fortunately the sore ears were already healed and there was no tissue avail able for biopsy. A study of these two cases brings up the question as to direct transmission from one individual to another, and also the possibility, after all, of animal contact being an important considera tion. Experimentally the disease has ap parently been transmitted from man to animal by Wherry and Ray 6 . They report a supposed case of Parinaud's conjunctivitis in which pus aspirated from the preauricular gland was inocu lated subcutaneously into a white mouse, producing an infection charac terized by purulent conjunctivitis and death. Postmortem there was isolated from muscular abscesses a leptothrix, which grew only on egg medium, in cubator under partial tension and ana erobic condition. In the same human case the organism was successfully cultured directly from pus of the gland. Unfortunately the conjunctival lesions of the patient were not examined histologically, so that it remains uncer tain whether or not the case was actu ally one of Parinaud's conjunctivitis, and whether or not the organism was the same as that found by Verhoeff in the conjunctival lesions of his cases. 520 Commonwealth Ave.
REFERENCES.
1. Verhoeff and Derby. Arch, of Ophth., 1904, vol. XXXIII, p. 389. 2. Bernheimer. Klin. Monat. f. Augenh., 1906, vol. XLIV, p. 323. 3. Verhoeff. Arch, of Ophth., 1913, vol. XLIII, p. 345. 4. Verhoeff. Amer. Jour, of Ophth., October, 1918. 5. Lemoine. Jour. Amer. Med. Assn., 1924, vol. LXXXII, p. 537. 6. Wherry and Ray. Journ. Infectious Diseases, 1918, vol. XXII, p. 554.