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Journal of Case Reports and Images in Ophthalmology, Vol. 1, 2018.
J Case Rep Images Opthalmol 2018;1:100006Z17NA2018. www.edoriumjournals.com/ej/crj/jcrio
Ahmad et al. 1
CASE REPORT OPEN ACCESS
Subconjunctival loiasis: A rare case report
Nursyamsi Ahmad, Margaret Indirawati, Junaedi Sirajuddin, Sitti Wahyuni
ABSTRACT
Introduction: Subconjunctival Loiasis is the infestment of the nematode Loa loa, also known as “African eye worm” in tropical West and Central Africa. This disease is transferred to humans through the bite of the deer fly of the Chrysops genus. The adult filarial worm migrates through the subcutaneous tissues, occasionally to the subconjunctival space. This disease is rarely found in Indonesia while in Africa it is an endemic disease. This case reports a patient with subconjunctival infestation of Loa loa filaria. Case Report: A 42-year-old man was admitted due to the sensation of “moving things” in the right eye. This condition began three years ago when the patients lived in Africa as a labour. He also felt redness in his right eye but there was no decrease in visual acuity. Slit lamp examination revealed a live whitish mass moving slowly within the tissue in the infero-temporal subconjunctiva quadrant. The worm was removed surgically under topical anaesthesia and the parasitology examinations confirmed that it was an adult male Loa loa species. Treatment of maximum dose of Albendazole 200 mg twice a day, started for three weeks. There was no complaint after three months follow-up. Conclusion: Based on the history taking, ophthalmologic examination,
Nursyamsi Ahmad1, Margaret Indirawati1, Junaedi Sirajud-din1, Sitti Wahyuni1
Affiliation: 1Department of Ophthalmology, Faculty of Medi-cine, Hasanuddin University, Hasanuddin University Teach-ing Hospital, Makassar, Indonesia.Corresponding Author: Nursyamsi Ahmad, Department of Ophthalmology, Faculty of Medicine, Hasanuddin Univer-sity, Hasanuddin University Teaching Hospital, Makassar, Indonesia; Email: [email protected]
Received: 09 June 2018Accepted: 28 August 2018Published: 11 October 2018
laboratory findings and parasitological result, we concluded that this patient has subconjunctival loiasis which is extremely rare case in Indonesia.
Keywords: African eye worm, Loa loa filaria, Sub-conjunctival loiasis
How to cite this article
Ahmad N, Indirawati M, Sirajuddin J, Wahyuni S. Subconjunctival loiasis: A rare case report. J Case Rep Images Opthalmol 2018;1:100006Z17NA2018.
Article ID: 100006Z17NA2018
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doi: 10.5348/100006Z17NA2018CR
INTRODUCTION
Subconjunctival Loiasis is a nematode infestation in subconjunctiva caused by the Loa loa also known as “African eye worm” due to bizarre ocular manifestation in tropical West and Central Africa. The disease is transferred to humans through the bite of the vectors, female flies of the Chrysops genus [1–3].
The African Program for Onchocerciasis Control (APOC) conducted a massive mapping of loiasis in 11 countries that are potentially endemic using the Rapid Assessment Procedure for Loiasis (RAPLOA). The surveys showed high risk levels of loiasis in 10 countries where an estimated 14.4 million people live in high risk areas [4]. This disease attacks millions of people in Africa but is rarely found in other continents, generally in immigrants or African travellers. Actually, there are only case reports in sporadic countries: USA, Germany, Spain, Italy, Norway, Korea, Australia, Brazil as for instance [3]. Such a case has never been described in Indonesia.
CASE REPORT PEER REVIEWED | OPEN ACCESS
Journal of Case Reports and Images in Ophthalmology, Vol. 1, 2018.
J Case Rep Images Opthalmol 2018;1:100006Z17NA2018. www.edoriumjournals.com/ej/crj/jcrio
Ahmad et al. 2
CASE REPORT
A 42-year-old man was admitted due to the sensation of “moving things” in the right eye (Figure 1) Video 1. At first, he felt the sensation under the skin at his lateral canthus approximately a month before (Figure 2) Video 2. This condition started three years ago when the patients lived in Africa as a labour. He also felt redness in his right eye but there was no decrease in visual acuity. Slit lamp examination revealed slightly conjunctival hyperaemic and presence of live whitish mass moving slowly within the tissue in the infero-temporal subconjunctiva quadrant. He denied any previous ocular or systemic symptoms. Fundus photograph were unremarkable in both eyes Figure 3(A and B). There was no evidence of subcutaneous swelling on physical examination and other findings were unremarkable. Under topical anesthesia, a small incision was made in the inferior conjunctiva and the mass was extracted with a forceps. It was immediately placed in formalin and sent for an identification in Parasitology Department. The worm identified as adult male Loa loa (Figure 4).
Laboratory findings were normal, and no microfilariae were found in thick blood smears stained with Giemsa, collected from two different sites at 12 am. The patient was consulted to the Internist and received oral Albendazole 200 mg twice a day for three weeks.
Figure 1: Long curled adult worm in the subconjunctival space on clinical examination.
Figure 2: The adult filarial migrates through the subcutaneous tissues in the lateral canthus.
Figure 3(A and B): The fundus image within normal limit in both eyes.
VideosVideo 1: Long curled adult worm in the subconjunctival space that moving during clinical examination.
Video 2: The worm moving in the subcutaneous tissues in the lateral canthus.
Video URL: http://www.edoriumjournals.com/journal-of-case-reports-and-images-in-ophthalmology/archive/article-full-text/100006Z17NA2018
Journal of Case Reports and Images in Ophthalmology, Vol. 1, 2018.
J Case Rep Images Opthalmol 2018;1:100006Z17NA2018. www.edoriumjournals.com/ej/crj/jcrio
Ahmad et al. 3
DISCUSSION
Subconjunctival Loiasis is a nematode infestation in subconjunctiva tissue caused by the Loa loa. The vectors, female flies of the Genus Chrysops, are infected by ingesting human blood contaminated with the parasitic microfilariae. In flies, the parasite undergoes larval stage and deposited with the faeces on the host skin during the blood meal. Larvae penetrates the skin and develop into adult worm [1]. Endemic areas of Loiasis are found in the West and Central Africa, particularly in some areas
of southern Nigeria, southern Cameroon, Democratic Republic of Congo, northern Angola, southern Central African Republican and Sudan [5, 6]. Our case reported the first subconjunctival loiasis in Indonesia.
Loiasis transferred to humans through the bite of the deer fly of the Chrysops genus, (family Tabanidae) [1, 2]. The adult filarial migrates through the subcutaneous tissues, at 1 cm per minute and is frequently found under the eyelid skin or conjunctiva [1, 2]. In this case report, at the beginning, the patient felt the sensation of “moving things” under the skin at his lateral canthus of his right eye and one month later he felt the same sensation at subconjunctival area of his right eye. He didn’t feel any particulars symptoms like ocular pain, pruritus, conjunctival chemosis or tearing.
The microfilariae circulate in the blood throughout the daytime. Therefore, the blood sample should be collected during daylight because of the diurnal periodicity [1, 2]. The worm can live more than 15 years [1, 6]. Infection can be asymptomatic, but peripheral blood count often shows eosinophilia of 30–40% [2]. However, there was no evidence of microfilariae on thick blood smears probably due to low parasitaemia load and other laboratory findings were normal.
The physical examination was unremarkable and no evidence of Calabar swellings was found in this case report. Although many cases reported this migratory subcutaneous swelling, as the most common presentation of loaiasis, with the symptoms pruritic angioedema mainly located at the extremities and sometimes near the orbits, which result from a Type I hypersensitivity reaction to antigens released from the worm [2, 7].
The diagnose was made by identification of either microfilariae in the blood or adult worms in subcutaneous tissues or conjunctiva [1–3]. Based on the history taking, ophthalmologic examination, laboratory findings and parasitology result we confirmed that it was an adult male Loa loa species in subconjunctival tissue.
Surgical removal of the worm is advisable when it can be visualized near the eye , followed by antiparasitic treatment for widespread infestation and in order to reduce transmission [2, 6]. Diethylcarbamazine is generally given 2 mg/kg twice a day treatment for three weeks and repeated as necessary. Ivermectin 150 mg/kg may also be effective, but significant side effects have been reported in patients with prominent intravascular loiasis. Concurrent administration of corticosteroids and/or antihistamines may be necessary to minimize allergic reactions [2, 5].
In this case, under topical anesthesia, a small incision was made in the inferior conjunctiva and the worm was removed with a forceps, and the patient consulted to the internist and received oral Albendazole 200 mg twice a day for three weeks. Diethylcarbamazine and ivermectin have been typically used to reduce microfilaremia and adult worm, but Albendazole may be a better option because of its slower onset of action and lower risk of precipitating encephalopathy [2, 3].
Figure 4(A and B): An adult male Loa loa.
Journal of Case Reports and Images in Ophthalmology, Vol. 1, 2018.
J Case Rep Images Opthalmol 2018;1:100006Z17NA2018. www.edoriumjournals.com/ej/crj/jcrio
Ahmad et al. 4
CONCLUSION
After comprehensive physical and ophthalmology examination the diagnosis can be concluded as subconjunctival loa loa, that is incredibly rare in Indonesia.
REFERENCES
1. Albert DM, Jakobiec FA. Principles and Practice of Ophthalmology. 3ed. USA: W.B. Saunders Company; 2008.
2. Krachmer JH, Mannis MJ, Holland EJ. Cornea: Fundamentals, Diagnosis and Management. USA: Elsevier Mosby; 2016.
3. Passos RM, Barbosa CP, Almeida Jde S, Ogawa GM, Camargo LM. Subconjunctival Loa loa worm: First case report in Brazil. Arq Bras Oftalmol 2012 Jan–Feb;75(1):67–70.
4. Zouré HG, Wanji S, Noma M, et al. The geographic distribution of Loa loa in Africa: Rsults of large-scale implementation of the rapid assessment procedure for loiasis (RAPLOA). PLoS Negl Trop Dis 2011 Jun;5(6):e1210.
5. Johnson GJ, Minassian DC, Weale RA, West SK. The Epidemiology of Eye Disease. 3ed. London: Imperial College Press; 2012.
6. Aiello F, Palma S, Varesi C, Cerulli A, Valente R, Aiello L. A rare case report of Loa loa ocular filariasis. Eur J Ophthalmol 2010 Jan–Feb;20(1):237–9.
7. Cantor LB, Rapuano CJ, Cioffi GA. External disease and Cornea, Section 8. San Fransisco: American Academy of Ophthalmology; 2016.
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Author ContributionsNursyamsi Ahmad – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Margaret Indirawati – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedJunaedi Sirajuddin – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedSitti Wahyuni – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone.
Consent StatementWritten informed consent was obtained from the patient for publication of this case report.
Conflict of InterestAuthors declare no conflict of interest.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Copyright© 2018 Nursyamsi Ahmad et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
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