Parinaud’s Oculoglandular Syndrome: A Case in an Adult with Flea-Borne Typhus and a Review
Abstract
:1. Introduction
2. Case
3. Discussion
3.1. POGS Due to Bartonella henselae, the Agent of Cat Scratch Disease
3.2. POGS Due to Francisella tularensis
3.3. POGS Due to Rickettsial Infections
3.4. POGS Due to Sporotrichosis
3.5. Miscellaneous Causes of POGS
3.6. Lymphatic and Ocular Involvement in Flea-Borne Typhus
3.7. Diagnostic Approach to POGS
4. Conclusions
Author Contributions
Funding
Conflicts of Interest
Disclosure
References
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Analyte | Day of Hospitalization | Value | Reference Range | Units |
---|---|---|---|---|
Sodium | 1 | 133 | 136–145 | mmol/L |
Potassium | 1 | 3.2 | 3.5–5.1 | mmol/L |
Aspartate Aminotransferase | 1 | 71 | 13–39 | IU/L |
Alanine Aminotransferase | 1 | 86 | 7–52 | IU/L |
C-Reactive Protein | 1 | 14.5 | 0–1 | mg/dL |
Magnesium | 1 | 1.8 | 1.9–2.7 | mg/dL |
Phosphorous | 1 | 1.5 | 2.5–5.0 | mg/dL |
Urine Protein | 1 | 100 | 0 | mg/dL |
Platelet Count | 3 | 109 | 150–400 | 103/µL |
Procalcitonin | 3 | 1.62 | <0.5 | ng/mL |
Creatinine Kinase | 3 | 277 | 30–233 | U/L |
Ferritin | 5 | >1500 | 10–322 | ng/mL |
D-Dimer | 5 | 623 | 0–230 | ng/mL |
White Blood Cell Count | 5 | 14.5 | 4–10 | 103/µL |
Lactate Dehydrogenase | 6 | 462 | 140–271 | IU/L |
No., [ref], Year | Age (y), Sex | Brief Course |
---|---|---|
1, [22], 1980 | 13, F | Cat exposure. Presented with fever, malaise for 2 w. L pa and bilat sm swelling. Palpebral conjunctiva with large granuloma. R submandibular biopsy showed microabscesses and giant cells consistent with CSD. Resolved after 2 w w/o treatment. |
2, [23], 1990 | 50, M | Cat scratch of eyelid, followed in 2 w by unilat eyelid swelling, ipsilat parotid swelling/pa and cervical LAD. Lymph node biopsy showed epithelioid granulomata with foreign body and Langerhans giant cells, with central necrosis. Three weeks after presentation, signs resolved. |
3, [21], 1991 | 49, M | Cat bite on upper lip 4 w prior to presenting with 3-d history of swollen L eyelids, a red eye w/mucopurulent discharge, and tender L pa LAD. Bulbar and tarsal conjunctivae injected w/follicles on the lower palpebral conjunctiva and diffuse papillary reaction. A 3-mm nodule present on bulbar conjunctiva. Tetracycline and topical sulfacetamide prescribed. Conjunctival biopsy interpreted as lymphoma. Warthin–Starry stain negative for Bartonella. When the patient returned 3 w later for a second biopsy, the conjunctivitis and LAD had resolved. A Hanger–Rose skin test + for CSD. |
4, [24], 1994 | 29, M | Patient with HIV infection with kitten exposure developed redness and irritation of L eye, tender L pa node and ulcerated nodule of inferior fornix. Received oral cipro for 2 w and topical cipro 4-times a day. Eye redness initially improved but worsened 2 months later. The conjunctival nodule was again present. Failed oral erythromycin and topical tobramycin/dexamethasone. Given 1 month of oral cipro and rifampin with marked improvement. Conjunctiva swab PCR + for Bartonella. |
5, [18], 1999 | 38, F | Cat owner; 2-w history of pa LAD; presented with L red eye; L eyelid with subtarsal papillae/large follicles; L bulbar conjunctiva w/granuloma/ulceration, episcleritis; given tobramycin/chloramphenicol eye drops, amox–clav, doxy; + B. henselae IgG; mild retinitis; LAD improved in 3 d; all signs and symptoms resolved over 3 w; late growing + culture. |
6, [25], 2003 | 14, F | Contact with kitten. Presented with 12-d history of redness in R eye and pa swelling; received: cephalexin 5 d; amox 4 d; gentamicin 3 d. On exam, conjunctival hyperemia and granuloma on the bulbar conjunctiva; pa and sm LAD. Received spiramycin for 3 d, then clarithromycin for 15 d, and trimethoprim/sulfamethoxazole for 10 d; + B. henselae IgG. All symptoms resolved after 2 months. |
7, [26], 2004 | 65, M | Presented with L eye irritation, conjunctival chemosis, and pa LAD. Scratched by kitten one week prior. Granulomatous nodule on palpebral conjunctiva. Initially B. henselae seronegative. Given cipro for 4 w; ocular findings improved after 4 days. Three weeks after first negative serologic test, + B. henselae IgG. |
8, [19], 2017 | 33, F | History of cat exposure; progressive swelling of L eyelid over 4 w; fever; L pa, sm, parotid, cervical swelling; granulomatous lesion of tarsal conjunctiva; started amox–clav/doxy; + B. henselae IgG; stopped amox–clav; finished 2 w of doxy with clinical resolution. |
9, [15], 2018 | 5, F | Cat contact; presented with 2-month history of excoriation below L eye; ipsilat pa, sm LAD; pus aspirated from pa mass; + B. henselae IgM; received 5-d azithro; resolved within 2 months. |
10, [27], 2018 | 28, M | Kitten exposure. Presented with headache, progressed to fever, fatigue, myalgia, and conjunctivitis and upper eyelid weakness w/ipsilat pa LAD; + B. henselae IgG. Improvement with 5-d azithro. |
11, [20], 2019 | 67, F | Two week history of unilat red eye, chemosis; slit lamp showed a conjunctival granuloma. Topical gatifloxacin/prednisolone acetate initiated; + B. henselae IgG. After 1 w, fever and ipsilat pa/sm LAD. Azithro resulted in regression of systemic and ocular disease. |
12, [28], 2020 | 66, F | History of cat scratch of hand, followed 1 w later with R parotid mass/cervical LAD and ipsilat red eye. CT revealed necrotic cervical LAD, necrotic nodules in R parotid gland. Pt had R follicular conjunctivitis and uveitis. Slit lamp showed mild anterior vitritis w/o anterior segment reaction. Parotid biopsy revealed necrotizing granulomas with central stellate microabscesses. B. henselae seropositive. Doxycycline given for 10 d. Two months after treatment, there was resolution. |
Abbreviations: amox–clav, amoxicillin–clavulanate; azithro, azithromycin; bilat, bilateral; CT, computerized tomograph; cipro, ciprofloxacin; doxy, doxycycline; ipsilat, ipsilateral; pa, preauricular; L, left; LAD, lymphadenopathy; PCR, polymerase chain reaction; R, right; sm, submandibular; unilat, unilateral. |
No., [ref], y | Age (y), Sex | Brief Course |
---|---|---|
13, [36], 1976 | 67, F | Blood from tick squirted into patient’s eye, causing L conjunctivitis. Failed neomycin/polymyxin B/bacitracin eye ointment x 7-d and 1-d sulfacetamide; then L pa, anterior cervical LAD and corneal clouding. Started intravenous cephalothin and streptomycin and gentamicin eye drops. Initial serology tests negative: Salmonella, Weil–Felix, Brucella, F. tularensis. Repeat serologic testing positive for F. tularensis. Gradual improvement on cephalothin and streptomycin. |
14, [37], 2001 | 17, F | Presented with chills, fatigue, cough, vomiting, diarrhea. One week later, painful nodule on L neck, followed by L eye pain and redness and nodules on legs and arms. Received amox–clav. Developed R conjunctivitis and R-sided cervical LAD. F. tularensis seropositive; received 5-d intramuscular streptomycin but fever returned; given methylprednisolone, potassium iodide; eye and skin findings regressed quickly. LAD resolved over 4 months. |
15, [38], 2001 | 18, M | History of rabbit exposure. presented with 4-day history of swollen L upper lid, injected L eye, tender pa, postauricular, and sm LAD, fever, chills, sweats, and headaches. Symptoms persisted despite cephalexin; large granulomatous follicles on L palpebral conjunctivae. A conjunctival culture showed grew F. tularensis. Given intramuscular streptomycin and intravenous nafcillin. Over several days, patient’s symptoms and signs improved. Back to baseline health within 2 months. |
16, [39], 2012 | 18, F | L conjunctivitis, periocular ecchymosis, tender pa/sm LAD; F. tularensis seropositive; resolved after 21 d of doxy. |
17, [40], 2012 | 44, M | Presented w/headache and swelling of R cheek and eyelids; treated with amox–clav and topical tobra. On exam, follicular conjunctivitis, ulcerating lesion on lower eyelid, and pa LAD. F. tularensis detected in aspirate of parotid lymph node. No improvement despite clarithromycin, clindamycin, gent, doxy, cipro for at least one week. The cervical node swelling did not regress and was excised. The ocular symptoms resolved. |
18, [40], 2012 | 68, M | Farmer w/cough and L-sided otalgia; treated with amox–clav; developed fever, L pa/parotid LAD, blepharitis, conjunctival injection, and ocular motility pain. A smear of the exudate indicated F. tularensis; recovered after 14 d of doxy. |
19, [35], 2013 | 15, M | One month history of R eye hyperemia, eyelash crusting; developed R pa/sm swelling. + F. tularensis seropostiv; placed on a 14-d course of gent. Hyperemia resolved; persistent pa/sm swelling. Placed on streptomycin and cipro. Allergy to cipro, changed to tetracycline. MRI showed involvement of R parotid gland and R masseter. LAD did not resolve despite antibiotics for 62 d, so affected lymph nodes excised, showing necrotizing granulomatous adenitis. Streptomycin stopped 10 day after surgery; resolved after tetracycline for 8 w. |
20, [41], 2013 | 27, F | Pregnant female presented with fever, headache, and generalized pain of a 2-w duration; R purulent conjunctivitis, dacryocystitis, pa/sm LAD; treated with amox–clav, gent eye drops; conjunctivitis resolved in 1 w; dacryocystitis drained; F. tularensis seropositive; pt declined systemic antibiotics; dacryocystitis relapsed; drained again; cipro-impregnated sponge placed in surgical site; finished 14-d amox–clav; recovered. |
21, [42], 2018 | 88, M | Presented with R eye pain and discharge; treated with lubricant and anti-inflammatory drops. Two months later, developed painful cervical mass and weight loss. F. tularensis detected by PCR of lymph node aspirate. Resolved after 14-d streptomycin. |
22, [43], 2019 | 13, F | Presented with 1 d of fever, sore throat, right papillary conjunctivitis with discharge, swelling of eyelids, sm LAD; started amox–clav; topical ofloxacin and polymyxin/neomycin started. Conjunctival swab, culture, and PCR + for F. tularensis. Switched to cipro for 14 d with resolution. Four days before presentation, she was picking goldenrod and rubbed her right eye. |
Abbreviations: amox–clav, amoxicillin–clavulanate; gent, gentamicin; ipsilat, ipsilateral; LAD, lymphadenopathy; MRI, magnetic resonance imaging; pa, preauricular; PCR, polymerase chain reaction; sm, submandibular; unilat, unilateral. |
No., ref, Year | Age (y), Sex | Etiology | Brief Course |
---|---|---|---|
23, [4], 2014 | 11, F | Rickettsia typhi/felis | Possible cat exposure. Fever, tender L pa LAD with ipsilat conjunctivitis. Failed clindamycin. L upper lid edema, admitted with vanco/ceftriaxone coverage. Antibiotics changed to azithro on d-2, then discharged on azithro d-3. Returned d-4 with fever, headache, bandemia, elevated AST/ALT. Doxy started. B. henselae IgG negative. IgM R. typhi 1:64 (convalescent 1:1024). Infection resolved over 10 d. |
24, [4], 2014 | 13, M | R. typhi/felis | Admitted with 3 d of fever, R pa swelling with ipsilat conjunctivitis for 6 d; failed clindamycin x 2 d. CT showed 1.5 × 1.5 cm pa LAD with surrounding cellulitis w/o abscess, R facial edema. Bandemia, elevated AST/ALT. Given ceftriaxone. Routine cultures negative. Given gent for possible tularemia on hospital day (HD) 3. Doxy started on HD4. B. henselae and F. tularensis seronegative. R typhi 1:1024 IgG, 1:512 IgM. |
25, [44], 1988 | 15, F | R. conorii | Removed ticks from dog, followed in one week by R conjunctivitis and eyelid swelling, pa LAD; then developed fever and rash. Resolved after 7 days of doxy. Serologic testing positive for R. conorii infection. |
26, [45], 1997 | 33, F | R. conorii | Removing ticks from a dog, splashed blood in her L eye; 1 w later developed L eyelid erythema/swelling, mucopurulent discharge, conjunctival hyperemia, chemosis, a granulomatous nodule on bulbar conjunctiva, small corneal ulcer, and ipsilateral pa/sm LAD. Conjunctival swabs for bacterial, fungal, and chlamydial cultures negative. Started topical chloramphenicol and rolitetracycline and IM piperacillin; developed fever, headache, arthralgia, myalgia, and rash; positive Weil–Felix test. Stopped piperacillin, received doxy for 2 w with complete resolution. |
27, [46], 2015 | 66, M | R. conorii | One month history of conjunctivitis L eye, treated with topical tobra, oflox, fusidic acid w/o improvement. On exam, swollen eyelids, conjunctival hyperemia, chemosis, mucopurulent discharge, and ipsilateral pa LAD. Prior to symptoms, eye exposed to contaminated water. Did not recall tick bite. Culture and serology for CSD, syphilis, Lyme Disease, and Chlamydia negative. Serologic testing positive for R. conorii infection. Resolved after 2-w doxy. |
Abbreviations: ac, anterior cervical; amox–clav, amoxicillin–clavulanate; AST/ALT, aspartate aminotransferase/alanine aminotransferase; cipro, ciprofloxacin; doxy, doxycycline; EM, erythema multiforme; LAD, lymphadenopathy; oflox, ofloxacin; pa, preauricular; sm, submandibular; tobra, tobramycin. |
No., [ref]. Year | Age (y), Sex | Brief Course |
---|---|---|
28, [49], 2014 | 21, M | Cat scratch to finger; 2 months later presented with persistent crusted lesion; then developed right eye lesion on tarsal conjunctiva and pa LAD. Fungal culture with S. schenckii. Responded to itraconazole. |
29, [50], 2002 | 34, M | Presented w/nodular lesion right eye; received consecutive treatment with topical neomycin–polymyxin B, naphazoline, prednisolone, and tobramycin–dexamethasone over 6 w. Exam showed 1-cm mass on bulbar conjunctiva with episcleral injection and right pa LAD. Biopsy of mass revealed suppurative granulomatous inflammation and yeast. Culture grew S. schenckii. Treatment with itraconazole suspension 200 mg each day. Two weeks after biopsy, exam showed multiple conjunctival infiltrates. Started topical fluconazole and itraconazole increased to 300 mg each day; gradual improvement and then resolution. |
30, [51], 2016 | 59, F | History of cat contact. Presented with erythema and pain of left bulbar conjunctiva for 75 days, followed by left cervical and retroauricular LAD and ulcerated nodules of the neck and arms. Culture of eye secretions grew Sporothrix sp. Treatment with itraconazole 200 mg/day for 60 days afforded complete resolution. |
Abbreviations: LAD, lymphadenopathy; pa, preauricular |
No., [ref], Year | Age (y) Sex | Etiology | Brief Course |
---|---|---|---|
31, [52], 1987 | 12, F | Pasteurella multocida | History of cat scratch and tick bite 3 w prior. Presented with R keratoconjunctivitis with pa, sm LAD. Failed 4 months of antibiotic therapy. Biopsy with culture of sm lymph node and cornea identified P. multocida. Tetracycline, chloramp and corticosteroid eye drops led to almost complete resolution of symptoms. |
32, [53], 1977 | 77, F | Yersinia enterocolitica | Presented with R eye swelling/pain; prior drainage of dacryocystic abscess. Found to have diabetic ketoacidosis; developed decreased visual acuity/fistulous tract of medial canthus. R palpebral conjunctiva with follicles/necrotic ulcers. Developed corneal ulcer/pa, sm LAD. Received: IM gentamicin, 14 d; methicillin on days 1/2; carbenicillin on days 2–6; intraocular gent every other day X 6 doses; gent eye drops. Corneal ulcer repaired. Exudate cultures grew Yersinia enterocolitica. Ocular inflammation and LAD resolved over 6 w, but corneal graft opacified. |
33, [54], 1988 | 17, F | Chlamydia trachomatis L2 | Two week history of bilat ocular pain, redness, and discharge; bilat sm, ant cervical LAD; tarsal papillary/follicular reaction; exophytic lesions of bulbar conjunctivae; R eye with corneal perforation. Treated with cefazolin–gent. McCoy cells inoculated w/conjunctival scrapings showed C. trachomatis inclusions; + Chlamydia IgG; patient had vaginal discharge, inguinal LAD; received 4 w of tetracycline and infection resolved. |
34, [55], 1998 | 56, M | Nocardia brasiliensis | Seven days after soil exposure presented with 4-d history of L eyelid swelling; given cefuroxime, 2 d later, developed pa, sm swelling; given IV cefazolin, topical gent; rapid improvement after 5 d of antibiotics; lost to follow-up. |
35, [56], 2018 | 5, M | M tuberculosis | Presented with painful R eye, excessive lacrimation, cough, chills, night sweats, weakness, weight loss; painful R pa, sm LAD and bilat inguinal/axillary LAD. HIV test negative; + Mantoux test; eyelid biopsy showed caseating granulomas. Placed on anti-TB therapy; after 2 w, decreased eyelid swelling/conjunctival injection and improved visual acuity. |
36, [57], 2008 | 51, F | EBV | History of rheumatoid arthritis on methotrexate. Three-week history R upper lid edema, conjunctivitis with pa LAD; rash that slowly resolved. Biopsy of tarsal conjunctiva: chronic granulomatous inflammation. Biopsy of lymph node: caseating granuloma; negative bacterial/AFB/fungal stains. Serologic test + for acute EBV infection. Evaluation negative for mumps, CMV, varicella, HSV, parvovirus, ricketttsiae, tularemia, leptospirosis, syphilis, listeriosis, ornithosis, borreliosis, actinomycosis, nocardiosis. Ocular and lymph node manifestations gradually resolved. |
37, [58], 2007 | 14, F | HSV-1 | Five day history of L conjunctival injection, periorbital swelling/tenderness, tender ipsilat pa/sm LAD and fever + headache. Vesiculopustules on lower lid developed on hospital day-3. Failed amoxicillin, clarithromycin, topical ofloxacin. Negative bacterial/fungal/F. tularensis cultures. Bartonella seronegative. Conjunctival swab + HSV-1 by PCR and indirect fluorescent antibody. |
38, [59], 1992 | 17, M | HSV-1 | Developed ulcer of R neck 1 w prior to admission. Two days later, had R conjunctival redness and drainage, periorbital swelling and pa, sm LAD. Developed fever, received cephalexin. Pt had R follicular conjunctivitis, and blepharitis with vesiculopustules at lid margin. Cultures from conjunctiva and neck ulcer grew HSV-1. Acyclovir and cefazolin given. Corticosteroid and idoxuridine eye drops given. Defervescence in 48 h. On hospital day 5, conjunctival inflammation markedly reduced and improvement of neck lesion. Oral acyclovir given for 1 more week. Resolution occurred by 3 w after discharge. |
39, [60], 2002 | 31, M | Paracoc-cidioides braziliense | Five months of cervical LAD, fever, malaise, weight loss. R eye pain, purulent drainage, R pre- and retroauricular LAD. Lymph node biopsy specimen and sputum grew P. braziliense. Improved after 3 w of trimethoprim–sulfamethoxazole. |
Abbreviations: ac, anterior cervical; AFB, acid fast bacillus; amox–clav, amoxicillin–clavulanate; cipro, ciprofloxacin; ctx, ceftriaxone; chloramp, chloramphenicol; doxy, doxycycline; EBV, Epstein–Barr virus; IM, intramuscular; L, left; LAD, lymphadenopathy; HSV, herpes simplex virus; pa, preauricular; PCR, polymerase chain reaction; R, right; sm, submandibular; tobra, tobramycin. |
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Dixon, M.K.; Dayton, C.L.; Anstead, G.M. Parinaud’s Oculoglandular Syndrome: A Case in an Adult with Flea-Borne Typhus and a Review. Trop. Med. Infect. Dis. 2020, 5, 126. https://doi.org/10.3390/tropicalmed5030126
Dixon MK, Dayton CL, Anstead GM. Parinaud’s Oculoglandular Syndrome: A Case in an Adult with Flea-Borne Typhus and a Review. Tropical Medicine and Infectious Disease. 2020; 5(3):126. https://doi.org/10.3390/tropicalmed5030126
Chicago/Turabian StyleDixon, M. Kevin, Christopher L. Dayton, and Gregory M. Anstead. 2020. "Parinaud’s Oculoglandular Syndrome: A Case in an Adult with Flea-Borne Typhus and a Review" Tropical Medicine and Infectious Disease 5, no. 3: 126. https://doi.org/10.3390/tropicalmed5030126