We report a literature review and a case of ocular toxoplasmosis in a patient with multiple drug allergies, who was successfully treated with regular intravitreal clindamycin and subconjunctival dexamethasone. A Malay lady in her twenties presented to us with right eye blurring of vision of 2 weeks duration, which she described as a central scotoma. Visual acuity at presentation was hand movements. Examination revealed intense ocular inflammation. The right eye had anterior segment inflammation of 3+ cells with fine keratic precipitates, whilst the posterior segment revealed papillitis, vitritis, retinitis, choroiditis, vasculitis and hyperpigmented chorioretinal scar inferotemporal to fovea. Ocular coherence tomography showed intraretinal fluid and retinal thickening. Fluorescein angiography showed early hypofluorescence of the lesion with progressive hyperfluorescence and leakage from the optic disc. Immunoglobulin G serology of Toxoplasma gondii was raised and immunoglobulin M levels were normal. The patient developed an allergic reaction with classical antibiotic and antifolate therapy. She was successfully treated with regular two-weekly intravitreal clindamycin and subconjunctival dexamethasone and her best corrected visual acuity was 6/18 at the end of her treatment. Intravitreal injection of clindamycin and subconjunctival dexamethasone is a good option in patients of ocular toxoplasmosis who are allergic to oral medications.
Toxoplasmosis, Ocular

Acanthamoeba Keratitis/epidemiology* ; Hospitals ; Humans ; Referral and Consultation ; Retrospective Studies ; Singapore/epidemiology*

PURPOSE: This study sought to describe the different clinical features and presentations of primary ocular toxoplasmosis in a setting not demonstrating an outbreak of disease.METHODS: This was a retrospective review of patients presenting to uveitis management services in Auckland and Hamilton, New Zealand between 2003 to 2018 with uveitis and positive toxoplasmosis immunoglobulin M serology.RESULTS: We identified 16 patients with primary acquired toxoplasmosis infection and ocular involvement. The mean age was 53 years. Systemic symptoms were reported in 56% (9 / 16). Visual acuity was reduced to 20 / 30 or less in 50% of patients (8 / 16). A single focus of retinitis without a pigmented scar was the salient clinical feature in 69% (11 / 16). Optic nerve inflammation was the sole clinical finding in 19% (3 / 16). Bilateral arterial vasculitis was the sole clinical finding in 13% (2 / 16). A delay in the diagnosis of toxoplasmosis of more than two weeks occurred in 38% (6 / 16) due to an initial alternative diagnosis. Antibiotic therapy was prescribed in all cases. Vision was maintained or improved in 69% (11 / 16) at the most recent follow-up visit (15 months to 10 years). Relapse occurred in 69% (11 / 16), typically within four years from the initial presentation.CONCLUSIONS: Primary ocular toxoplasmosis presenting in adulthood is a relatively uncommon cause of posterior uveitis in New Zealand. This condition should be considered in any patient presenting with retinitis or optic nerve inflammation without a retinochoroidal scar. This disease tends to relapse; thus, close follow-up is required.
Cicatrix ; Diagnosis ; Follow-Up Studies ; Humans ; Immunoglobulin M ; Inflammation ; New Zealand ; Optic Nerve ; Recurrence ; Retinitis ; Retrospective Studies ; Toxoplasmosis ; Toxoplasmosis, Ocular ; Uveitis ; Uveitis, Posterior ; Vasculitis ; Visual Acuity

Acanthamoeba castellanii has ubiquitous distribution and causes primary acanthamoebic keratitis (AK). AK is a common disease in contact lens wearers and results in permanent visual impairment or blindness. In this study, we observed the cytopathic effect, in vitro cytotoxicity, and secretion pattern of cytokines in human corneal epithelial cells (HCECs) induced by A. castellanii trophozoites and/or cysts. Morphological observation revealed that panked dendritic HCECs co-cultured with amoeba cysts had changed into round shape and gradually died. Such changes were more severe in co-culture with cyst than those of co-cultivation with trophozoites. In vitro cytotoxicity assay revealed the highest cytotoxicity to HCECs in the co-culture system with amoeba cysts. A. castellanii induced the expression of IL-1α, IL-6, IL-8, and CXCL1 in HCECs. Secreted levels of IL-1α, IL-6, and IL-8 in HCECs co-cultured with both trophozoites and cysts were increased at an early incubation time (3 and 6 hr). These results suggested that cytopathic changes and pro-inflammatory cytokines release of HCECs in response to A. castellanii, especially amoebic cysts, are an important mechanism for AK development.
Acanthamoeba castellanii ; Acanthamoeba ; Amoeba ; Blindness ; Coculture Techniques ; Cytokines ; Epithelial Cells ; Humans ; In Vitro Techniques ; Interleukin-6 ; Interleukin-8 ; Keratitis ; Trophozoites ; Vision Disorders

Acanthamoeba, one of free-living amoebae (FLA), remains a high risk of direct contact with this protozoan parasite which is ubiquitous in nature and man-made environment. This pathogenic FLA can cause sight-threatening amoebic keratitis (AK) and fatal granulomatous amoebic encephalitis (GAE) though these cases may not commonly be reported in our clinical settings. Acanthamoeba has been detected from different environmental sources namely; soil, water, hot-spring, swimming pool, air-conditioner, or contact lens storage cases. The identification of Acanthamoeba is based on morphological appearance and molecular techniques using PCR and DNA sequencing for clinico-epidemiological purposes. Recent treatments have long been ineffective against Acanthamoeba cyst, novel anti-Acanthamoeba agents have therefore been extensively investigated. There are efforts to utilize synthetic chemicals, lead compounds from medicinal plant extracts, and animal products to combat Acanthamoeba infection. Applied nanotechnology, an advanced technology, has shown to enhance the anti-Acanthamoeba activity in the encapsulated nanoparticles leading to new therapeutic options. This review attempts to provide an overview of the available data and studies on the occurrence of pathogenic Acanthamoeba among the Association of Southeast Asian Nations (ASEAN) members with the aim of identifying some potential contributing factors such as distribution, demographic profile of the patients, possible source of the parasite, mode of transmission and treatment. Further, this review attempts to provide future direction for prevention and control of the Acanthamoeba infection.
Acanthamoeba ; Amoeba ; Animals ; Asia, Southeastern ; Asian Continental Ancestry Group ; Encephalitis ; Humans ; Keratitis ; Nanoparticles ; Nanotechnology ; Parasites ; Plants, Medicinal ; Polymerase Chain Reaction ; Sequence Analysis, DNA ; Soil ; Swimming Pools ; Water

Acanthamoeba keratitis (AK) is a rare sight-threatening corneal infection, often reporting from contact lens wearers. An asymptomatic human immunodeficiency virus (HIV)-infected Thai male without history of contact lens use complained foreign body sensation at his left eye during motorbike riding. He had neither specific keratitis symptoms nor common drugs responding, which contributed to delayed diagnosis. By corneal re-scraping, Acanthamoeba-like cysts were detected by calcofluor white staining and agar culture. The etiological agent obtained from the culture was molecularly confirmed by Acanthamoeba spp.-specific PCR, followed by DNA sequencing. The results from BLAST and phylogenetic analysis based on the DNA sequences, revealed that the pathogen was Acanthamoeba T4, the major genotype most frequently reported from clinical isolates. The infection was successfully treated with polyhexamethylene biguanide resulting in corneal scar. This appears the first reported AK case from a non-contact lens wearer with HIV infection in Thailand. Although AK is sporadic in developing countries, a role of free-living Acanthamoeba as an opportunistic pathogen should not be neglected. The report would increase awareness of AK, especially in the case presenting unspecific keratitis symptoms without clinical response to empirical antimicrobial therapy.
Acanthamoeba Keratitis ; Acanthamoeba ; Agar ; Asian Continental Ancestry Group ; Base Sequence ; Corneal Injuries ; Delayed Diagnosis ; Developing Countries ; Foreign Bodies ; Genotype ; HIV Infections ; HIV ; Humans ; Keratitis ; Male ; Off-Road Motor Vehicles ; Polymerase Chain Reaction ; Sensation ; Sequence Analysis, DNA ; Thailand

This prospective study was aimed to detect acute and chronic ocular toxoplasmosis by comparison of anti-Toxoplasma gondii IgM and IgG antibody levels and IgG avidity test. One hundred and seventeen patients with ocular toxoplasmosis (OT) who referred to the Farabi Eye Hospital, Tehran, Iran were included in this study. Of the patients, 77 cases were positive for anti-T. gondii IgG, and 8 cases were positive for anti-T. gondii IgM. IgG avidity test revealed 11, 4, and 102 cases were low, intermediate, and high, respectively, and 6.8% and 9.4% of cases were positive for IgM and IgG avidity tests, respectively (P=0.632). Agreement (Kappa value) between paired tests IgG-IgM, IgG-IgG avidity, and IgM-IgG avidity was 0.080, 0.099, and 0.721, respectively (P < 0.05). This study showed that conventional serologic tests (IgM and IgG levels) and IgG avidity correlate well each other and can be used to differentiate recent infections from old OT. It seems that reactivated old infections rather than recently acquired infections are majority of Iranian OT patients.
Antibodies ; Diagnosis ; Humans ; Immunoglobulin G ; Immunoglobulin M ; Iran ; Prospective Studies ; Serologic Tests ; Toxoplasma ; Toxoplasmosis, Ocular

Members of genus Acanthamoeba are widely distributed in the environment. Some are pathogenic and cause keratitis and fatal granulomatous amoebic encephalitis. In this study, we isolated an Acanthamoeba CJW/W1 strain from tap water in Wuxi, Jiangsu Province, China. Its 18S rDNA was sequenced and a phylogenetic tree was constructed. The isolated cysts belonged to morphologic group II. Comparison of 18S rDNA sequences of CJW/W1 strain and other isolates showed high similarity (99.7%) to a clinical isolate Asp, KA/E28. A phylogeny analysis confirmed this isolate belonged to the pathogenic genotype T4, the most common strain associated with Acanthamoeba-related diseases. This is the first report of an Acanthamoeba strain isolated from tap water in Wuxi, China. Acanthamoeba could be a public health threat to the contact lens wearers and, therefore, its prevalence should be monitored.
Acanthamoeba ; China ; DNA, Ribosomal ; Encephalitis ; Genotype ; Keratitis ; Phylogeny ; Prevalence ; Public Health ; Trees ; Viperidae ; Water

Pathogenic Acanthamoeba spp. cause granulomatous amoebic encephalitis and keratitis. Acanthamoeba keratitis (AK) is a rare but serious ocular infection that can result in permanent visual impairment or blindness. However, pathogenic factors of AK remain unclear and treatment for AK is arduous. Expression levels of proteins secreted into extracellular space were compared between A. castellanii pathogenic (ACP) and non-pathogenic strains. Two-dimensional polyacrylamide gel electrophoresis revealed 123 differentially expressed proteins, including 34 increased proteins, 7 qualitative increased proteins, 65 decreased proteins, and 17 qualitative decreased proteins in ACP strain. Twenty protein spots with greater than 5-fold increase in ACP strain were analyzed by liquid chromatography triple quadrupole mass spectrometry. These proteins showed similarity each to inosine-uridine preferring nucleoside hydrolase, carboxylesterase, oxygen-dependent choline dehydrogenase, periplasmic-binding protein proteinases and hypothetical proteins. These proteins expressed higher in ACP may provide some information to understand pathogenicity of Acanthamoeba.
Acanthamoeba castellanii ; Acanthamoeba Keratitis ; Acanthamoeba ; Blindness ; Carboxylesterase ; Choline Dehydrogenase ; Chromatography, Liquid ; Electrophoresis, Polyacrylamide Gel ; Encephalitis ; Extracellular Space ; Eye Infections ; Keratitis ; Mass Spectrometry ; Peptide Hydrolases ; Virulence ; Vision Disorders

Pathogenic Naegleria fowleri, Acanthamoeba castellanii, and Acanthamoeba polyphaga, are distributed worldwide. They are causative agents of primary amoebic meningoencephalitis or acanthamoebic keratitis in humans, respectively. Trophozoites encyst in unfavorable environments, such as exhausted food supply and desiccation. Until recently, the method of N. fowleri encystation used solid non-nutrient agar medium supplemented with heat-inactivated Escherichia coli; however, for the amoebic encystment of Acanthamoeba spp., a defined, slightly modified liquid media is used. In this study, in order to generate pure N. fowleri cysts, a liquid encystment medium (buffer 1) modified from Page’s amoeba saline was applied for encystation of N. fowleri. N. fowleri cysts were well induced after 24 hr with the above defined liquid encystment medium (buffer 1). This was confirmed by observation of a high expression of differential mRNA of nfa1 and actin genes in trophozoites. Thus, this liquid medium can replace the earlier non-nutrient agar medium for obtaining pure N. fowleri cysts. In addition, for cyst formation of Acanthamoeba spp., buffer 2 (adjusted to pH 9.0) was the more efficient medium. To summarize, these liquid encystment media may be useful for further studies which require axenic and pure amoebic cysts.
Acanthamoeba ; Acanthamoeba castellanii ; Actins ; Agar ; Amoeba* ; Desiccation ; Escherichia coli ; Food Supply ; Humans ; Hydrogen-Ion Concentration ; Keratitis ; Meningoencephalitis ; Methods ; Naegleria fowleri ; RNA, Messenger ; Trophozoites