Granulomatous Conjunctivitis

Pink Eye or Red Eye 2 (Granulomatous)

Pink eye or red eye has been covered in the pink eye or red eye article, and these terms are basically used to indicate conjunctivitis by the layman and that the definition of conjunctivitis, its causes, general signs, symptoms and treatment have already been dealt in the first post of pink eye or red eye.

This post is the sequelae of the red or the pink eye in which all the granulomatous conditions or long term or chronic pathologies causing the conjunctivitis or the red eye would be discussed.

What are Granulomatous Diseases

Granulomatous conditions or diseases are those in which there is formation of a granuloma.What happens is there are some microorganism or pathogens which are not easily destroyed by the immune system of our body. The cells of the immune system are not able to destroy them even after engulfing some of these pathogens.

So the other stronger cells of the body which are responsible for giving the protection in case of long term infection start to appear at the site of pathogen residual and starts engulfing them although they are also not able to kill them all resulting in collection of the inflammatory cells, giant cells and lymphocytes at the periphery and the necrotic cell structure (which has been destroyed by the microbes or pathogens) in the centre thus forming what is called a granuloma and the conditions in which this granuloma formation takes place are called the granulomatous conditions.

Therefore the granulomatous conditions are mainly caused by the tough microorganisms like the mycobacteria and are usually chronic or say long term infections.

What is Granulomatous Conjunctivitis

Granulomatous ConjunctivitisIn granulomatous conjunctivitis, there is mainly unilateral involvement of the eye that is there is conjunctivitis mainly in one eye with the formation of an inflammatory granuloma which is present or say localised to the route of the entry of the pathogen through the conjunctiva.

Various infectious agents causing conjunctivitis or pink or the red eye are:

  • Chlamydia trachomatis (serovarieties L1, L2, L3)
  • Rochalimaea henselae
  • Mycobacterium tuberculosis
  • Treponema pallidum
  • Francisella tularensis
  • Mycobacterium leprae

[*] If this granulomatous conjunctivitis that is mainly unilateral conjunctivitis with formation of a localised granuloma is also accompanied by lymphadenopathy of the regional or the surrounding areas (swelling of the lymph node), it is called parinaud oculoglandular syndrome.

Conditions causing Granulomatous Conjunctivitis

  • Parinaud oculoglandular syndrome
  • Cat scratch disease
  • Lymphogranuloma venereum
  • Tuberculosis of the conjunctiva
  • Syphilis (conjunctivitis)
  • Tularemia
  • Leprosy

Cat Scratch Disease

Cat Scratch DiseaseThis type of granulomatous conjunctivitis is caused by microorganism Rochalimaea henselae. It is called Cat scratch disease because there is a history of being licked or scratched by a cat 2 weeks or less before the symptoms arise.

Also the infected cat carries the microorganism, which on coming of the cat in contact with humans licking (infected saliva) or scratching inoculates it into the skin or eye (conjunctiva), causing the systemic disease and if the conjunctiva is the entry route then it causes conjunctivitis. It generally causes swelling of the lymph nodes too thus results in parinaud oculoglandular syndrome.

The diagnosis is made on history of cat licking and scratching and can be confirmed by serological tests and Hanger Rose cat scratch skin test.

The disease resolves itself in 4 – 6 weeks, so there is only a need to give supportive treatment. The usual medication is tetracycline or trimethoprim-sulfamethoxazole combination or ciprofloxacin which are given orally for four weeks. Topical eye drops gentamicin can be given for four times a day along with topical eye ointment to be applied four times a day.

Tuberculosis of the conjunctiva

Tuberculosis ConjunctivaMycobacterium tuberculosis is a gram positive, acid fast, rod like organism and because of the mycolic acid present in its cell wall resists staining.It mainly causes systemic disease tuberculosis but it can also cause granulomatous conjunctivitis although its incidence of causing granulomatous conjunctivitis is very rare.

Sometimes if the infection is from structure other than the eye or the conjunctiva, it can present as the only sign or symptom in an individual who has the systemic disease but otherwise does not have any other signs or symptoms.

  • It is seen to be occurring in mainly young people and usually causes ulceration.
  • It can present in many clinical forms in the eye.
  • The ulcers could be multiple.They are mainly present on the palpebral conjunctiva and are small miliary ulcers.
  • It can also present as follicular conjunctivitis that is follicles in the conjunctiva or as gelatinous exudates in the fornix.
  • It can also present as polyp like growth with a stalk or a typical nodule at the limbus.

Infact the ulceration of the conjunctiva should always arise the suspicion of the following pathological conditions:

  • Tuberculosis
  • Foreign body
  • Syphilis

There is usually less pain unless the ulceration is severe and this also causes swelling of the regional nodes and can result in parinauds’s oculoglandular syndrome.

The diagnosis can be made on the basis of conjunctival scrapings or lymph node biopsies which show typical granuloma formation and caseous necrosis on histopathology.

The lesion is usually excised particularly if it is the primary route of entry or can be scraped properly and cauterized by diathermy.

ATT (anti-tubercular treatment) must be given in all the cases.

Syphilis

Syphilis ConjunctivaSyphilis which is caused by the spirochaete Treponema pallidum can also cause granulomatous conjunctivitis in the eye.

Primary chancre stage which is due to invasion of the conjunctiva with the treponema by contact with an oral infected lesion is very rare.

The primary chancre here is less indurated than the usual genital primary chancre. This primary chancre if present in the palpebral conjunctiva can be mistaken for a chalazion.

A chronic ulcer or the gumma stage of the syphilis in the conjunctiva is relatively more common.

There is a formation of the gummation ulcer more commonly in the bulbar conjunctiva than in the palpebral conjunctiva.

Lymph nodes enlargement also take place in this condition and as the others it can also manifest as parinaud oculoglandular syndrome.

Diagnosis is made by taking the scrapings of the lesion and examining it for microorganisms by dark ground microscopy and serological tests.

Treatment is with the topical tetracycline and systemic penicillin.

Tularemia

It is caused by the organism Francisella tularensis and this organism is mainly derived from animals such as squirrels sheep, deer, cattle etc. The vectors of this disease are also there and they can be ticks or deer flies. It enters the human body through abraded skin or mucous membrane of the conjunctiva and also through tick bite. It can present as nodules or ulcers in the tarsal conjunctiva.

It also causes typical parinaud oculoglandular syndrome with manifestations of lymph node enlargement, fever, headache and general weakness. The diagnosis is made by agglutination test.

The treatment is by streptomycin and topical gentamicin drops till the condition resolves.

Lymphogranuloma Venereum

It is a highly infectious venereal disease caused by Chlamydia trachomatis mainly strains L1, L2, L3. The clinical features are typical and start with a vesicle which bursts and leaves behind a grey ulcer. There is also accompanying lymph node enlargement.

Treatment is with antibiotic Azithromycin 1g single dose. Other drugs include doxycycline, erythromycin or ofloxacin.

Parinaud Oculoglandular Syndrome

Parinaud oculoglandular syndrome occurs when there is unilateral conjunctivitis with formation of a localised granuloma is also accompanied by lymphadenopathy of the regional or the surrounding areas (swelling of the lymph node).

Therefore in parinaud oculoglandular syndrome, mainly there is conjunctivitis which is of follicular type and enlargement of preauricular or submandibular lymph nodes of the same or the affected eye.Various diseases which cause this syndrome are:

  • Cat scratch disease
  • Tularemia
  • Tuberculosis
  • Mumps
  • Ssyphilis
  • Lymphogranuloma venereum
  • Infectious mononucleosis
  • Fungal infections
  • Lymphomas
  • Leukaemias
  • Sarcoidosis
  • Patient complains of redness, mucopurulent discharge, and foreign body sensation.

Signs are follicular conjunctivitis, lymphadenopathy, fever, weakness. Fever can be with or without rash.

Treatment includes:

  • Warm compresses locally to the region of enlarged tender lymph nodes
  • Analgesics
  • Anti pyretics
  • Specific therapy for the disease.

Reference

1. Parsons, Diseases of the eye 21st Edition Page no.175-176.