Reports on HIV/AIDS: 1990

MARCH 23, 1990, MMWR, Vol. 39, No. 11, pp. 188-189
Microsporidian Keratoconjunctivitis in Patients with AIDS
From November 1989 through January 1990, five cases of ocular infections with
microsporidia in patients with acquired immunodeficiency syndrome (AIDS) were
reported. Three cases were identified in New York City (1), one in San Antonio, and
one in Cleveland (2). All five patients were homosexual men aged 29-46 years. The
most common presenting manifestations were conjunctivitis or scleritis (all patients),
foreign-body sensation (four patients), blurred vision (three patients), and photophobia (three patients). Ophthalmologic examinations found conjunctival inflammation
(all patients), decreased visual acuity (four patients), and diffuse punctate keratopathy
(four patients). One patient had corneal inflammation, and one patient had corneal
ulceration. Pathologic findings were bilateral in all patients. Concomitant, unilateral
cytomegalovirus retinitis was noted in two patients. After routine bacterial and fungal
cultures failed to identify plausible etiologic agents, corneal or conjunctival scrapings
and/or biopsy specimens were obtained from all patients. Sections from these
specimens prepared with Giemsa and other routine histologic stains contained
numerous oval, dark-staining organisms consistent in morphology with microsporidian spores. Visualization of characteristic ultrastructure with transmission
electron microscopy confirmed the diagnosis in all cases.
Two of the five patients have died of other AIDS-related complications. No
improvement in their ocular infections was noted before death despite attempted
treatment with various topical antimicrobial (tobramycin, chloramphenicol, and
sulfisoxazole), lubricating, and anti-inflammatory agents (1). Two other patients did
not respond to therapy with topical antimicrobial agents (neomycin, propamidine
isethionate, amphotericin, sulfacetamide, and trimethoprim/sulfamethoxazole); however, several weeks after therapy was discontinued the symptoms resolved. The
reason for these improvements is unknown, but both patients coincidentally began
systemic therapy with fluconozole or itraconazole for concomitant cryptococcal
meningitis. Infection in the fifth patient failed to respond to topical preparations
(cefazolin, propamidine isethionate, and clotrimazole); one cornea perforated, and
the patient underwent emergency corneal grafting.
One patient wore contact lenses; none had histories of ocular trauma. Use of other
eye medications by patients is unknown. Two patients had histories of foreign travel.
Four patients were exposed to domestic animals: one had cared for a friend's pet cat,
two others kept pet birds (parrot and parakeets) in their homes, and one had both a
pet cat and a pet bird. The exact source of infection in all five cases remains unknown.
Reported by: JM Orenstein, MD, George Washington Univ Medical Center, District of Columbia.
J Seedor, MD, New York Eye and Ear Infirmary; DN Friedberg, MD, SM Stenson, MD, PM Tierno,
PhD, NC Charles, MD, New York Univ Medical Center, New York City, New York. DM Meisler,
MD, CY Lowder, MD, JT McMahon, PhD, DL Longworth, MD, I Rutherford, MD, Cleveland Clinic
Foundation, Cleveland, Ohio. RW Yee, MD, A Martinez, MD, F Tio, MD, K Held, MD, Univ of Texas
Health Sciences Center, San Antonio, Texas. Parasitic Diseases Br, Div of Parasitic Diseases,
Center for Infectious Diseases, CDC.
Editorial Note: Microsporidia are ubiquitous, spore-forming, intracellular protozoal
parasites that cause disease in a wide range of vertebrate and invertebrate animals.
Manifestations of disease in humans range from asymptomatic infections to fulminant cerebritis and/or nephritis; ocular infections are recognized infrequently (3,4).

41