Ophthalmic Infection Case Studies

CASE 1
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An eight-year-old boy who has been in good health attends a summer camp for two weeks. When he returns home, his mother notices that he has a mild runny nose and a very slight fever. The boy mentions that "something was going around" during the last few days of his stay at the camp, so his mother assumes that this is just a typical "summer cold." However, the boy's runny nose is more pronounced the next day, and he develops a mild sore throat and nonproductive cough. When he awakens the following morning, his left eye is swollen, and he says that it feels like there is "something stuck" in the eye. By lunchtime, the boy's right eye is also noticeably swollen and there is a little more discomfort in the left eye. His mother examines him and notices that the insides of both the upper and lower eyelids look bloody, especially in the left eye. Moreover, his tears appear to contain a small quantity of blood. At this point, the boy's mother becomes very concerned and takes him to the family pediatrician, where they have to wait for almost three hours because they don't have an appointment and there are many other walk-in patients ahead of them.

On examination (late in the afternoon), the boy's vital signs are normal, except for the low-grade fever (38.2ºC). He now has blurred vision in his left eye, and there is a tender, palpable lymph node just in front of his left ear. Vision in the boy's right eye is still normal. The bulbar and palpebral conjunctivae in each eye have a granular or pebbled appearance, and they are both quite inflamed. Aside from a runny nose and somewhat irritated throat, the only other remarkable finding is mild cervical adenopathy. The physician asks about the boy's recent activities and learns that he recently attended a summer camp.

Question 1.1: What is your diagnosis?

Question 1.2: What is the likely causative agent?

Question 1.3: What other diseases does this causative agent produce?

Question 1.4: What age groups are most affected by this agent?

Question 1.5: How is this disease transmitted?

Question 1.6: How can you treat this case?

CASE 2

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Suppose that you are a new family practice physician and that you spend one weekend each month working in a mobile clinic that goes to underserved neighborhoods in a nearby large city. This weekend, the clinic is serving a neighborhood that is populated primarily by immigrants from North Africa and the Middle East. Most of the residents are quite poor and cannot afford regular medical care. They can call 911 for life-threatening situations (such as a heart attack), but they often have to wait for weeks or even months-until a clinic like yours shows up-to get help for other problems.

Your first patient this weekend is a 34-year-old man who presents with a bad eye infection. The conjunctivae of his right eye are badly inflamed and scarred. The eyelids have become distorted, apparently from the scarring, and have turned inward, so that the eyelashes now constantly abrade the surface of the eyeball. The cornea also appears to be badly damaged, with inflammatory leukocytic infiltrations and superficial vascularization (i.e., pannus formation). Parts of the corneal epithelium are badly abraded an ulcerated, and there is scarring in some of these areas. Not surprisingly, the vision in this eye is very much reduced.

In taking the patient's history, you learn that he grew up in a small village in rural Egypt, where there was no running water. He moved to the U.S. about 12 years ago. When asked about previous eye problems, he remembers that the same eye was infected when he was 13 years old (and still living in the remote village). The symptoms he remembers indicate that he probably had a relatively severe form of conjunctivitis.

Question 2.1: What is your diagnosis?

Question 2.2: What is the causative agent?

Question 2.3: What other eye diseases does this agent cause?

Question 2.4: What non-eye diseases does this agent cause?

Question 2.5: How is this disease transmitted?

Question 2.6: Where is this disease endemic?

Question 2.7: How important is this disease?

Question 2.8: How should you treat this case?

CASE 3

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A 10-year-old boy who has a couple of active cold sores wakes up one morning with a painfully inflamed right eye. His mother takes him to a local clinic, where his eye is examined. The conjunctivae are clearly inflamed, but the cornea looks clear and there are no other remarkable symptoms. A preliminary diagnosis of bacterial or early adenoviral conjunctivitis is made, so the boy is treated with a topical antibiotic preparation (in case his infection is bacterial) and given an eye patch to wear. His mother is told to bring him back after three days for a follow-up examination.

When the boy is reexamined three days later, it is obvious that the condition of his eye has not improved. If anything, the inflammation is even worse than it was before. Moreover, numerous small vesicles (i.e., fluid-filled lesions) have appeared on the conjunctivae and the periocular skin, and vision in the affected eye is blurred. The patient's tears are not tinged with blood, and there are no other remarkable findings.

Question 3.1: What is your preliminary diagnosis?

Question 3.2: How is the diagnosis confirmed?

Question 3.3: Is this a dangerous situation?

Question 3.4: How should you treat this case?

Question 3.5: How was the boy's eye infected?

Question 3.6: What other diseases does this agent cause?

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