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Sporotrichosis of the Eyelid
SPOROTRICHOSIS OF THE EYELID B. Y. A L V I S , M . D . SAINT LOUIS
Sporothrix, distinctly pathogenic, was several times recovered from linear excoriations in the conjunctiva of three eyelids of the same patient. But the progress under potassium iodide and tinc ture of iodine has not been very satisfactory.
The case here reported differs in practically every clinical respect from cases described in rather numerous previous reports from different sources, and is reported as sporotrichosis only because on three occasions, several weeks apart, a sporothrix of decided pathogenicity was recovered from scrapings of the lesions. Case: Mrs. N. B., age 34 years, a mulatto woman, has been under treat ment in the Washington University out-patient department for trachoma since September, 1919. The condition was in a chronic state when she was first observed, the lids showing the velvety appearance of a trachoma of long standing with some scarring of the cornea. From time to time ulcers of the cornea have appeared and healed under treatment. There is at present a moderate entropion of the lower lids and some fine lashes appear, which have to be removed to prevent irritation of the cornea. In March, 1927, a narrow white line was observed extending along the margins of the right upper, right lower, and left lower lids, for approximately two-thirds of their length, being in each instance some two to three millimeters in width and representing a shallow excoriation of the conjunctiva filled with a cheesy material easily removed by a blunt instrument or cottonwrapped applicator. The base of the excoriations was slightly granular in appearance, very pale gray in color, never bleeding and never painful. No sign of inflammation appeared in or about these excoriations. They did not heal and they progressed exceedingly slowly if a t all. A smear made March 21, 1927, stained with methylin blue, showed rounded organisms resembling yeast bodies. Cultures sent to the clinical bacteriological laboratory were reported hemolytic staphylococcus and streptococcus.
Numerous antiseptic and astringent solutions were employed locally. The patient had a negative Wassermann but was given a course of mercury bichloride intramuscularly (15 m. of one percent solution), because the lids and corneas gave evidence of un controlled chronic trachoma. After six or eight weeks of treatment, during which time the patient was using locally some mild antiseptics (protargol one percent and optochin one percent), lids and corneas showed marked diminution of inflammatory signs. The eyes became quite comfortable when troublesome lashes were kept out. The linear excoria tions along the lid margins, however, showed little signs of healing, and on October 21, 1927, scrapings from these lesions were cultured on various media, both aerobically and anaerobically. A smear made a t this time showed diphtheroid organisms in abundance and a less numerous gram-negative bacillus, both since found to be nonpathogenic. A few sporothrix colonies were found, which grew poorly at first but readily on transplantation. White rats in oculated with the organism died in a few days, showing the characteristic gumma-like lesions in the lungs from which the sporothrix was again re covered. Treatment is now being given with potassium iodide by mouth and local applications of tincture of iodine, but so far the progress has been rather disappointing. For some time there has been less irritation, but the excoriative lesions along the lid margins are still present. As stated at the outset, this picture differs markedly from that generally described. The typical lesion is a gumma-like nodule which gumma-like may appear in any tissue, but which is most commonly found on the skin and mucous surfaces. The eye cases have been reported most frequently in the 381
382
B. Y. ALVIS
lids and conjunctiva, but others are reported in the lacrymal duct and sac, on the bulbar conjunctiva, the cornea, the iris, and even the retina. The super ficial infections are usually ectogenous in origin, while the intraocular ap pearance of the disease usually ac companies a generalized sporotrichosis endogenous so far as the eye is con cerned. The lesions are rather acutely inflammatory in nature, with redness, swelling, rupture, and discharge of scant ily purulent nature producing fistulous openings very slow in healing and very resistant to local treatment. The con tent of the nodule is gelatinous. There is marked accompanying adenitis and often constitutional manifestations of fever, malaise and so on. Conjunctival cases closely simulate Parinaud's disease, being distinguished from it mainly by culture and recovery of the sporothrix and by the size of the nodules. The organism was first recovered from human lesions by Schenck in 1898, and is called Sporothrix schenckii. A similar sporothrix reported by Beurmann from similar lesions exhibited some cultural variations and was named after this author. Serum reactions in a case reported by Wilder and McCullough indicate the identity of the two organ isms. The first American case involving the eye was reported by H. Gifford in 1910. This case was confirmed by culture. He also described five other cases similar clinically, but not confirmed by culture. The second case culturally proven was by Wilder and McCullough 1 , who gave an account of accidental inocula tions from cultures in the conjunctivas of one of the authors. Eleven days later appeared symptoms of acute inflamma tion of the conjunctiva, with nodule formation, pain, swelling, regional
lymphadenitis, and rather violent con stitutional disturbance. Recovery in about two months followed administra tion of potassium iodide. Bedell, 1914, reported the fourth proven American case, while in 1922 and 1924 S. R. Gifford added the re maining two cases up to now in this country. The latter in a comprehensive review of the literature summarizes some thirty-two cases reported from all sources, mostly from France. These in clude cases involving the skin of the lids, the conjunctiva, lacrimal sac, in terior of the globe, and brow and orbit and lids combined. The intraocular lesions are secondary to generalized sporotrichosis, the infection being bloodborne. There is a notable variation in the course and severity of the cases reported. Some were acutely inflammatory in nature, with marked local and general symptoms. Others ran a chronic course with extensive destruction of tissue, in some even the entire globe being dis organized. In still others the lesions amounted to no more than a small suppurating nodule with very little effect on surrounding structures and almost no symptoms. The treatment consists in the exhibi tion of potassium iodide by mouth in doses of from two to eight grains per day. This is apparently a specific, and almost all cases have yielded to it in reasonable time, although in some it was of questionable benefit. A few nodules have been excised as being re sistant to medical treatment. I t is noteworthy that many cases of sporothrix infection of various parts of the body are reported from the Miss issippi valley. Doubtless many more cases have occurred, both involving the eyes and otherwise, than have ap peared in the literature. Carlelon building.
Bibliography (Note. Since practically all reported cases are summarized and listed in the following no at tempt1 is made to give a complete list here.) Wilder and McCullough. Jour. Amer. Med. Assoc, 1914, v. 72, p. 1156. s Bedell. Proc. Amer. Ophth. Soc, 1914, v. 13, p. 720. 3 Gifford, S. R. Arch, of Ophth., 1922, v. 51, p. 540.
Sporothrix, distinctly pathogenic, was several times recovered from linear excoriations in the conjunctiva of three eyelids of the same patient. But the progress under potassium iodide and tinc ture of iodine has not been very satisfactory.
The case here reported differs in practically every clinical respect from cases described in rather numerous previous reports from different sources, and is reported as sporotrichosis only because on three occasions, several weeks apart, a sporothrix of decided pathogenicity was recovered from scrapings of the lesions. Case: Mrs. N. B., age 34 years, a mulatto woman, has been under treat ment in the Washington University out-patient department for trachoma since September, 1919. The condition was in a chronic state when she was first observed, the lids showing the velvety appearance of a trachoma of long standing with some scarring of the cornea. From time to time ulcers of the cornea have appeared and healed under treatment. There is at present a moderate entropion of the lower lids and some fine lashes appear, which have to be removed to prevent irritation of the cornea. In March, 1927, a narrow white line was observed extending along the margins of the right upper, right lower, and left lower lids, for approximately two-thirds of their length, being in each instance some two to three millimeters in width and representing a shallow excoriation of the conjunctiva filled with a cheesy material easily removed by a blunt instrument or cottonwrapped applicator. The base of the excoriations was slightly granular in appearance, very pale gray in color, never bleeding and never painful. No sign of inflammation appeared in or about these excoriations. They did not heal and they progressed exceedingly slowly if a t all. A smear made March 21, 1927, stained with methylin blue, showed rounded organisms resembling yeast bodies. Cultures sent to the clinical bacteriological laboratory were reported hemolytic staphylococcus and streptococcus.
Numerous antiseptic and astringent solutions were employed locally. The patient had a negative Wassermann but was given a course of mercury bichloride intramuscularly (15 m. of one percent solution), because the lids and corneas gave evidence of un controlled chronic trachoma. After six or eight weeks of treatment, during which time the patient was using locally some mild antiseptics (protargol one percent and optochin one percent), lids and corneas showed marked diminution of inflammatory signs. The eyes became quite comfortable when troublesome lashes were kept out. The linear excoria tions along the lid margins, however, showed little signs of healing, and on October 21, 1927, scrapings from these lesions were cultured on various media, both aerobically and anaerobically. A smear made a t this time showed diphtheroid organisms in abundance and a less numerous gram-negative bacillus, both since found to be nonpathogenic. A few sporothrix colonies were found, which grew poorly at first but readily on transplantation. White rats in oculated with the organism died in a few days, showing the characteristic gumma-like lesions in the lungs from which the sporothrix was again re covered. Treatment is now being given with potassium iodide by mouth and local applications of tincture of iodine, but so far the progress has been rather disappointing. For some time there has been less irritation, but the excoriative lesions along the lid margins are still present. As stated at the outset, this picture differs markedly from that generally described. The typical lesion is a gumma-like nodule which gumma-like may appear in any tissue, but which is most commonly found on the skin and mucous surfaces. The eye cases have been reported most frequently in the 381
382
B. Y. ALVIS
lids and conjunctiva, but others are reported in the lacrymal duct and sac, on the bulbar conjunctiva, the cornea, the iris, and even the retina. The super ficial infections are usually ectogenous in origin, while the intraocular ap pearance of the disease usually ac companies a generalized sporotrichosis endogenous so far as the eye is con cerned. The lesions are rather acutely inflammatory in nature, with redness, swelling, rupture, and discharge of scant ily purulent nature producing fistulous openings very slow in healing and very resistant to local treatment. The con tent of the nodule is gelatinous. There is marked accompanying adenitis and often constitutional manifestations of fever, malaise and so on. Conjunctival cases closely simulate Parinaud's disease, being distinguished from it mainly by culture and recovery of the sporothrix and by the size of the nodules. The organism was first recovered from human lesions by Schenck in 1898, and is called Sporothrix schenckii. A similar sporothrix reported by Beurmann from similar lesions exhibited some cultural variations and was named after this author. Serum reactions in a case reported by Wilder and McCullough indicate the identity of the two organ isms. The first American case involving the eye was reported by H. Gifford in 1910. This case was confirmed by culture. He also described five other cases similar clinically, but not confirmed by culture. The second case culturally proven was by Wilder and McCullough 1 , who gave an account of accidental inocula tions from cultures in the conjunctivas of one of the authors. Eleven days later appeared symptoms of acute inflamma tion of the conjunctiva, with nodule formation, pain, swelling, regional
lymphadenitis, and rather violent con stitutional disturbance. Recovery in about two months followed administra tion of potassium iodide. Bedell, 1914, reported the fourth proven American case, while in 1922 and 1924 S. R. Gifford added the re maining two cases up to now in this country. The latter in a comprehensive review of the literature summarizes some thirty-two cases reported from all sources, mostly from France. These in clude cases involving the skin of the lids, the conjunctiva, lacrimal sac, in terior of the globe, and brow and orbit and lids combined. The intraocular lesions are secondary to generalized sporotrichosis, the infection being bloodborne. There is a notable variation in the course and severity of the cases reported. Some were acutely inflammatory in nature, with marked local and general symptoms. Others ran a chronic course with extensive destruction of tissue, in some even the entire globe being dis organized. In still others the lesions amounted to no more than a small suppurating nodule with very little effect on surrounding structures and almost no symptoms. The treatment consists in the exhibi tion of potassium iodide by mouth in doses of from two to eight grains per day. This is apparently a specific, and almost all cases have yielded to it in reasonable time, although in some it was of questionable benefit. A few nodules have been excised as being re sistant to medical treatment. I t is noteworthy that many cases of sporothrix infection of various parts of the body are reported from the Miss issippi valley. Doubtless many more cases have occurred, both involving the eyes and otherwise, than have ap peared in the literature. Carlelon building.
Bibliography (Note. Since practically all reported cases are summarized and listed in the following no at tempt1 is made to give a complete list here.) Wilder and McCullough. Jour. Amer. Med. Assoc, 1914, v. 72, p. 1156. s Bedell. Proc. Amer. Ophth. Soc, 1914, v. 13, p. 720. 3 Gifford, S. R. Arch, of Ophth., 1922, v. 51, p. 540.