Outbreak of microsporidial keratoconjunctivitis with rugby sport due to soil exposure

Abstract

Aims: To investigate a cluster of microsporidial keratoconjunctivitis in 33 eyes of 25 previously healthy paediatric and teenage individuals after a rugby match.

Methods: An observational case series was reported. Analysis of medical record of patients with microsporidial keratoconjunctivitis, who presented within May 2012, was performed. All patients were treated by a single ophthalmologist with a standardized topical regime, including a fluoroquinolone (moxifloxacin) and an antiseptic (Brolene or Desomedine). Five eyes received corneal scrapings.

Results: The mean age was 13.36 years (range 5-16). All patients have participated in a rugby match on 21-22 April 2012. The onset of symptoms ranged from 10 to 30 days post exposure. All eyes had multiple superficial coarse punctate keratitis. Four (12%) eyes presented with keratic precipitates. One (3%) eye had intraocular pressure of 27 mm Hg. Microscopic examination of corneal scrapings with modified trichrome or calcofluor white (CFW) fluorescent staining was unremarkable but subsequent PCR test was positive for the small subunit rRNA gene of Vittaforma corneae in three out of five eyes. Sequencing of the PCR product of 1150 bp showed 96-100% identity with the Indian or Singaporean strains of V. corneae. After treatment, all eyes healed without sequel.

Conclusions: The first outbreak of microsporidial keratoconjunctivitis in paediatric and teenage individuals with a rugby match is reported. A standardized topical regime, including a fluoroquinolone (moxifloxacin) and an antiseptic (Brolene or Desomedine), seems to be safe and effective, and requires validation in future treatment trials.

Figure 1

Patient No. 5. Slit-lamp photograph showing diffuse, multifocal, coarse, small, punctate, corneal epithelial lesions: (a) diffuse illumination (b) using fluorescein stain via cobalt blue filter.

Figure 2

(a) Photo of the gel electrophoresis showing the result of PCR assay for SSU rRNA of V. corneae with primer LPW20469 and LPW20470, giving a 1150-bp amplicon on three of the five corneal scrapings. Lanes: 1–3, patient 1–3: show positivity for V. corneae DNA; Lanes 4–5, patient 4 and 5: negative, showing no amplicon; Lane M, 100-bp plus marker; Lane NC, negative control. (b) Photo of the gel electrophoresis showing the result of PCR assay for SSU rRNA of V. corneae with primer LPW20475 and LPW20476 giving a 280-bp amplicon on three of the five corneal scrapings. Lanes: 1–3, patient 1–3: show positivity for V. corneae DNA; Lanes 4–5, patient 4 and 5: negative, showing no amplicon; Lane M, 100-bp plus marker; Lane NC, negative control.

Figure 3

(a) Phylogenetic tree of the 522-bp fragment of the SSU rRNA of V. corneae (only available fragment information in Indian strains) showing 100% nucleotide identity. (b) Phylogenetic tree of the 284-bp fragment of the SSU rRNA of V. corneae (only available fragment information in Singapore strains) showing 96–98% nucleotide identity.