Parinaud Oculoglandular Syndrome

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Disease Entity

Parinaud Oculoglandular Syndrome is a conjunctival disease characterized by a unilateral granulomatous follicular conjunctivitis associated with ipsilateral regional lymphadenopathy. There are many vectors that transmit and organisms that cause oculoglandular syndrome, of which, Cat Scratch Disease is the most common cause. Prognosis in most cases is excellent. [1]

Etiology[1]

Most common

Cat-Scratch Disease

Bartonella henselae

More common

Tularemia

Francisella tularensis

Sporotrichosis

Sporothrix schenckii

Less common

Tuberculosis

Mycobacterium tuberculosis

Coccidioidomycosis

Coccidioides immitis

Syphilis

Treponema pallidum

Rare

Herpes Simplex

Herpes virus

Sarcoidosis

Chancroid

Haemophilus ducreyi

Pasteurellosis

Pasteurella multocida

Yersinia sp.

Yersinia enterocolitica

Yersinia pseudotuberculosis

Hansen’s disease

Mycobacterium leprae

Listeria

Listeria monocytogenes

Mumps

Mumps virus

Infectious mononucleosis

Epstein-Barr virus

Blastomycosis

Blastomyces dermatitidis

Mediterranean fever

Rickettsia conorii

Vaccinia

Smallpox vaccine

Lymphogranuloma Venereum (LGV)

Chlamydia trachomatis-LGV subtype

Paracoccidioidomycosis

Paracoccidioides brasiliensis

Glanders

Burkholderia mallei

General Pathology

Cat-Scratch Disease

Cat-scratch disease (CSD) is a zoonosis caused by the bacterium Bartonella henselae, a small fastidious gram-negative bacillus. Parinaud oculoglandular syndrome occurs in 5-7% of patients with CSD.[2] [3]Immature domestic cats are the most frequently implicated vector with other sources including dogs, cat fleas, and sandflies.[4][5]

Tularemia

Tularemia is a zoonotic disease caused by the bacterium Francisella tularensis, a pleomorphic aerobic gram negative coccobacillus. A wide range of animals serve as reservoirs (rabbits, squirrels, game bird, muskrats, hamsters, prairie dogs, sheep, beavers, cats, tick, flea, and mosquito). F. tularensis can be aerosolized and it is also found in soil and water.[6]

Sporotrichosis

Sporotrichosis is a rare mycosis caused by Sporothrix schenckii, a dimorphic fungus existing in mycelial and yeast phase. Infection rates are higher in tropical and subtropical areas such as Brazil and Peru,[7] where Sporothrix schenckii is endemic. It is commonly found in plant organic matter (leaves, wood), soil, and water. [8] Sporothrix schenckii has also been recovered from animal fur, feces, and oral cavities (i.e. cats, horse, dogs, rabbits, and rats).[9]

History

Cat-Scratch Disease

The incubation period is typically from 3 days to 3 weeks. B. henselae is frequently transmitted through hand-to-eye contact or from contamination of an open wound.[2] Aerosolized cat flea feces is another proposed mechanism. Unlike other manifestations of CSD, the oculoglandular form rarely manifests after a scratch.[10] A higher number of cases are reported among children and veterinary workers. To evaluate for potential exposure, clinicians should assess for recent contact with cats, dogs, human body lice, sandflies, or fleas. [5]

Tularemia

Tularemia has an incubation period of approximately 2 to 5 days, and rarely up to 3 weeks. Infected individuals are typically meat-handlers, campers, or hunters who have had recent contact with animals or contaminated particles. The mechanism of ocular involvement is hand-to-eye contact, or splash from contaminated animal body fluids or water.[11] History should include recent travel, outdoor activities, game ingestion, handling of animal carcasses, and tick exposure.

Sporotrichosis

Sporotrichosis can be transmitted through traumatic inoculation of the skin with organic matter,[12] respiratory secretions,[7] and hand-to-eye contact with infected animal fluids.[13] Occupations or activities that have been associated with infection include plant or soil handling and contact with sick or healthy animals (i.e. gardener, miners, hunters, farmers, housewives, etc.).

Physical examination

Cat-Scratch Disease

Ocular signs of Cat-Scratch disease range from scant to serous and/or mucoid discharge, mild periorbital edema, conjunctival ulceration, and/or nodule/granuloma. A papule may appear at the site of inoculation. Patients typically develop non-tender lymphadenopathy (pre or post-auricular, submandibular, or cervical lymph nodes). [3][14][15] Less common manifestations are low grade fever, pain, and suppurative lymphadenopathy. It can take several weeks for the granuloma to resolve and several months for the regional lymphadenopathy to clear.[11]

Tularemia

Oculoglandular syndrome is a rare presentation of Tularemia (2-14%). Signs of ocular involvement include mucopurulent discharge, conjunctival chemosis, epithelial defects, ulceration, nodules, and periorbital edema. Less common ocular signs are dacryocystitis and corneal ulcer. Unique to Tularemia oculoglandular syndrome is the severity of systemic symptoms compared to other etiologies. Patients develop headaches, anorexia, fever, sore throat, and painful lymphadenopathy typically in the following regions: preauricular, submandibular, cervical, parotid, or axillary. [10][16]

Sporotrichosis

In Sporotrichosis oculoglandular syndrome, conjunctival granuloma and/or ulcer, eyelid ulcer, and purulent discharge are some common ocular findings.[7][8] Commonly associated signs with are non-tender preauricular and submandibular lymphadenopathy. Less commonly, patients experience painful lymphadenopathy, dacryocystitis,[7] or fever.[13]

Diagnosis

Cat-Scratch Disease

Cat-scratch disease is diagnosed with serology, culture,[17] or polymerase chain reaction (PCR).[18] In practice, serology is the most often used modality. Titers of immunoglobulin M (IgM) greater or equal to 1:20, immunoglobulin G (IgG) greater or equal to 1:256, or a fourfold increase in serum IgG titers between acute and convalescent phase are indicative of active infection.[3] If CSD is tested later in the disease course, IgM titers are typically low and IgG titers are high. Therefore, IgG titers of 1:512 are indicative of recent infection. Cultures are difficult to obtain and require long incubation periods. In the past, B. henselae was diagnosed using the Hanger-Rose test on lymph node aspirates.[19]

Tularemia

Tularemia is diagnosed with culture, serology, PCR, or direct fluorescent ab assay. Potential specimens are lymph node aspirates, conjunctival nodule biopsy, conjunctival swab or serum . Serologic titers greater than 1:128 indicate prior or current infection. Because it takes 2 weeks for titers to increase, the first samples should be obtained early, followed by repeat samples at day 14 and weeks 3 to 4. A fourfold increase in F. tularensis ab confirms an active infection. Titers greater than 1:160 at 2 to 3 weeks after onset of symptoms onset indicate an active infection.[10] For cultures, the organism needs a cysteine-enriched media to grow—such as modified Thayer-Martin media or chocolate agar (GCII agar with 1% haemoglobin and 1% IsoVitaleX).[20]

Sporotrichosis

Sporotrichosis is typically diagnosed with culture (Sabouraud 2%). If a conjunctival nodule is present, it can be biopsied and sent for histopathology (Gomori-methenamine-silver or periodic acid-Schiff (PAS) stains) or electron microscopy.[12]

Management

Cat-Scratch Disease

The role of antibiotic therapy in CSD has not been established in a controlled study. As CSD is generally self-limited, treatment is usually supportive. Broad-spectrum ophthalmic drops are used to prevent secondary infections.[19] Systemic antibiotics are recommended for moderate to severe disease. A wide variety of antibiotics and antibiotic combinations has been utilized to treat CSD including doxycycline, azithromycin, trimethoprim/sulfamethoxazole DS, ciprofloxacin, and rifampin. The duration of treatment varies depending on the patient’s clinical course, and should be individualized.[3][15]

Tularemia

For severe disease, first line agents are streptomycin or gentamicin for 7 to 14 days. For less severe disease, the recommended treatment is oral or intravenous doxycycline or ciprofloxacin for 14-21 days.[5] Topical treatment options are ciprofloxacin and tobramycin ophthalmic drops and or tobramycin ointment. [11] With therapy, ocular symptoms improve in approximately 1 week, overall recovery may be seen in 2 to 3 months.[10][21]

Sporotrichosis

There are no controlled studies to evaluate the effectiveness of antifungal agents. Currently, Sporotrichosis oculoglandular syndrome is treated with oral itraconazole, potassium iodide, or fluconazole. Topical fluconazole ophthalmic drops have also been utilized with success. Sporotrichosis typically responds well to treatment. Duration and treatment is usually weeks to months and symptoms resolve in 1 to 4 months. [9] [12][13]

References

  1. 1.0 1.1 Mannis MJ, Holland EJ. Cornea. 4th ed. St. Louis, Mo: Elsevier Inc.; 2015:518-525.
  2. 2.0 2.1 Carithers HA. Cat-scratch disease. An overview based on a study of 1,200 patients. American journal of diseases of children. 1985;139(11):1124-1133.
  3. 3.0 3.1 3.2 3.3 Murakami K, Tsukahara M, Tsuneoka H, et al. Cat scratch disease: analysis of 130 seropositive cases. Journal of infection and chemotherapy: official journal of the Japan Society of Chemotherapy. 2002;8(4):349-352.
  4. Cunningham ET, Koehler JE. Ocular bartonellosis. American journal of ophthalmology. 2000;130(3):340-349.
  5. 5.0 5.1 5.2 Ormerod LD, Dailey JP. Ocular manifestations of cat-scratch disease. Current opinion in ophthalmology. 1999;10(3):209-216.
  6. Nigrovic LE, Wingerter SL. Tularemia. Infectious disease clinics of North America. 2008;22(3):489-504, ix.
  7. 7.0 7.1 7.2 7.3 Ramirez Soto MC. Sporotrichosis in the Ocular Adnexa: 21 Cases in an Endemic Area in Peru and Review of the Literature. American journal of ophthalmology. 2016;162:173-179 e173.
  8. 8.0 8.1 Lopes-Bezerra LM, Schubach A, Costa RO. Sporothrix schenckii and sporotrichosis. Anais da Academia Brasileira de Ciencias. 2006;78(2):293-308.
  9. 9.0 9.1 Gordon DM. Ocular sporotrichosis; report of a case. Archives of ophthalmology. 1947;37(1):56-72.
  10. 10.0 10.1 10.2 10.3 Carithers HA. Oculoglandular disease of parinaud. A manifestation of cat-scratch disease. American journal of diseases of children. 1978;132(12):1195-1200.
  11. 11.0 11.1 11.2 Eren Gok S, Kocagul Celikbas A, Baykam N, et al. Evaluation of tularemia cases focusing on the oculoglandular form. Journal of infection in developing countries. 2014;8(10):1277-1284.
  12. 12.0 12.1 12.2 Hampton DE, Adesina A, Chodosh J. Conjunctival sporotrichosis in the absence of antecedent trauma. Cornea. 2002;21(8):831-833.
  13. 13.0 13.1 13.2 Schubach A, de Lima Barros MB, Schubach TM, et al. Primary conjunctival sporotrichosis: two cases from a zoonotic epidemic in Rio de Janeiro, Brazil. Cornea. 2005;24(4):491-493.
  14. Jawad AS, Amen AA. Cat-scratch disease presenting as the oculoglandular syndrome of Parinaud: a report of two cases. Postgraduate medical journal. 1990;66(776):467-468.
  15. 15.0 15.1 Galindo-Bocero J, Sanchez-Garcia S, Alvarez-Coronado M, Rozas-Reyes P. Parinaud's oculoglandular syndrome: A case report. Archivos de la Sociedad Espanola de Oftalmologia. 2017;92(1):37-39.
  16. Raja H, Starr MR, Bakri SJ. Ocular manifestations of tick-borne diseases. Survey of ophthalmology. 2016;61(6):726-744.
  17. Grando D, Sullivan LJ, Flexman JP, Watson MW, Andrew JH. Bartonella henselae associated with Parinaud's oculoglandular syndrome. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 1999;28(5):1156-1158.
  18. Le HH, Palay DA, Anderson B, Steinberg JP. Conjunctival swab to diagnose ocular cat scratch disease. American journal of ophthalmology. 1994;118(2):249-250.
  19. 19.0 19.1 Huang MC, Dreyer E. Parinaud's oculoglandular conjunctivitis and cat-scratch disease. International ophthalmology clinics. 1996;36(3):29-36.
  20. Kantardjiev T, Padeshki P, Ivanov IN. Diagnostic approaches for oculoglandular tularemia: advantages of PCR. The British journal of ophthalmology. 2007;91(9):1206-1208.
  21. Thompson S, Omphroy L, Oetting T. Parinaud's oculoglandular syndrome attributable to an encounter with a wild rabbit. American journal of ophthalmology. 2001;131(2):283-284.