Microsporidial Keratitis in Patients with Hot Springs Exposure

The early induction of interleukin (IL)-12 is a critical event in determining the development of both innate resistance and adaptive immunity to many intracellular pathogens. Previous in vitro studies have suggested that the macrophage (MΦ) is a major source of the initial IL-12 produced upon microbial stimulation and that this response promotes the differentiation of protective T helper cell 1 (Th1) CD4+ lymphocytes from precursors that are primed on antigen-bearing dendritic cells (DC). Here, we demonstrate by immunolocalization experiments and flow cytometric analysis that, contrary to expectation, DC and not MΦ are the initial cells to synthesize IL-12 in the spleens of mice exposed in vivo to an extract of Toxoplasma gondii or to lipopolysaccharide, two well characterized microbial stimulants of the cytokine. Importantly, this production of IL-12 occurs very rapidly and is independent of interferon γ priming or of signals from T cells, such as CD40 ligand. IL-12 production by splenic DC is accompanied by an increase in number of DCs, as well as a redistribution to the T cell areas and the acquisition of markers characteristic of interdigitating dendritic cells. The capacity of splenic DC but not MΦ to synthesize de novo high levels of IL-12 within hours of exposure to microbial products in vivo, as well as the ability of the same stimuli to induce migration of DC to the T cell areas, argues that DC function simultaneously as both antigen-presenting cells and IL-12 producing accessory cells in the initiation of cell-mediated immunity to intracellular pathogens. This model avoids the need to invoke a three-cell interaction for Th1 differentiation and points to the DC as both a sentinel for innate recognition and the dictator of class selection in the subsequent adaptive response.

To investigate the incidence and epidemiologic factors involved in the development of microsporidial keratitis. The association of host immune status and clinical pattern, clinical features, and the role of fluoroquinolone monotherapy in treatment are also examined. Retrospective, noncomparative case series. All cases (124 patients, 134 eyes) of microsporidial keratitis confirmed with modified trichrome stain positive of corneal scrape over a 4-year period. Epidemiologic factors were observed. Host immune status with human immunodeficiency virus (HIV) serology and CD4/CD8 analysis was performed when consent was obtained. Visual acuity (VA) and slit-lamp examination throughout the course of keratitis was recorded. Treatment used included topical fluoroquinolones (ciprofloxacin 0.3%, moxifloxacin 0.5%, gatifloxacin 0.5%, levofloxacin 0.5%, or norfloxacin 0.3%) as monotherapy or in combination with topical fumagillin and/or systemic albendazole. Where corneal edema developed, ultrasound corneal pachymetry was recorded. Demographic features and epidemiologic factors, including host immune status. Clinical features and disease course, including the response to different therapeutic regimes. Patients ranged in age from 11 to 68 years (mean, 31.9; median, 30) with a male:female ratio of 8:1 (females n = 17 [13.7%]). We performed HIV serology and CD4/CD8 in 45.9% of cases (n = 57); all the cases tested were negative with normal T-cell indices. Epidemiologic factors included soil exposure (50%), contact lens wear (21.1%), and topical steroid treatment (17.1%). The VA on presentation ranged from 20/20 to 20/100 (median, 20/30) with no loss in lines of VA on resolution. Common features were follicular papillary conjunctivitis and coarse punctate epithelial lesions in 3 patterns--diffuse, peripheral, and paracentral--evolving into nummular keratitis before resolution. Resolution occurred in 99% of cases on topical fluoroquinolone monotherapy. Four patients had recurrent disease that resolved with repeat fluoroquinolone or fluoroquinolone/oral albendazole combination. Two new clinical features were identified--diffuse endotheliitis (19.4%) with corneal edema and limbitis. This study identifies an increasing incidence of microsporidial keratitis in Singapore with a strong correlation with prior soil exposure. Diffuse endotheliitis and limbitis have not been described and resolves with topical steroid therapy. Topical fluoroquinolone monotherapy is a valid treatment option.

Microsporidia are eukaryotic spore forming obligate intracellular protozoan parasites first recognized over 100 years ago. These organisms infect all of the major animal groups and are now recognized as opportunistic pathogens of humans. Microsporidian spores are common in the environment and microsporidia pathogenic to humans have been found in water supplies. The genera Nosema, Vittaforma, Brachiola, Pleistophora, Encephalitozoon, Enterocytozoon, Septata (reclassified to Encephalitozoon) and Trachipleistophora have been found in human infections. These organisms have the smallest known eukaryotic genomes. Microsporidian ribosomal RNA sequences have proven useful as diagnostic tools as well as for phylogenetic analysis. Recent phylogenetic analysis suggests that Microsporidia are related to the fungi. These organisms are defined by the presence of a unique invasion organelle consisting of a single polar tube that coils around the interior of the spore. All microsporidia exhibit the same response to stimuli, that is, the polar tube discharges from the anterior pole of the spore in an explosive reaction. If the polar tube is discharged next to a cell, it can pierce the cell and transfer its sporoplasm into the cell. A technique was developed for the purification of polar tube proteins (PTPs) using differential extraction followed by reverse phase HPLC. This method was used to purify the PTPs from Glugea americanus, Encephalitozoon cuniculi, Enc. hellem and Enc. intestinalis. These PTPs demonstrate conserved characteristics such as solubility, hydrophobicity, mass, proline content and immunologic epitopes. The major PTP gene from Enc. cuniculi and Enc. hellem has been cloned and expressed in vitro. The gene sequences support the importance of ER and in the formation of the polar tube as suggested by morphologic studies. Analysis of the cloned proteins also indicates that secondary structural characteristics are conserved. These characteristics are probably important in the function of this protein during the eversion/assembly of the polar tube and in providing elasticity and resiliency for sporoplasm passage.