Chi nese Med i cal Jour nal (Taipei) 2002;65:498-500
Case Report
Phthiriasis Palpebrarum: An Unusual Blepharoconjunctivitis Yen-Ching Lin1,3 Shu-Ching Kao1,3 Hui-Chuan Kau2,3 Wen-Ming Hsu 1,3 Chieh-Chih Tsai1,3 1
De part ment of Oph thal mol ogy, Tai pei Vet erans Gen eral Hos pi tal, Tai pei; 2 De part ment of Oph thal mol ogy, Taoyuan Vet erans Hos pi tal, Taoyuan; 3 De part ment of Oph thal mol ogy, Na tional Yang-Ming Uni ver sity, Tai pei, Tai wan, R.O.C.
Key Words crab louse; phthiriasis palpebrarum; Phthirus pubis
P
Phthiriasis palpebrarum is an un usual cause of blepharoconjunctivitis and may eas ily be over looked be cause of the fail ure of phy si cians to rec og nize Phthirus pubis. We re port a case of a 30-year-old woman with per sis tent itch ing in the left eye lid which was un suc cess fully treated un der the di agno sis of al ler gic blepharoconjunctivitis. Care ful oph thal mic ex am i na tion re vealed seven bugs with mul ti ple red pin point ex cre tions and nu mer ous small trans lu cent oval eggs (nits) coat ing the eye lashes. The pa tient was suc cess fully treated with me chan i cal re moval of all the lice and nits from the eye lashes. The spec i men proved histopathologically to be the Phthirus pubis in fes ta tion. The Phthirus pubis in fes ta tion is usu ally as so ci ated with poor hy giene in over crowded or un de vel oped coun try. How ever, it may be come a no ta ble prob lem be cause of fre quent trav el ing and com mer cial ac tiv i ties across the dif fer ent coun tries. [Chin Med J (Taipei) 2002;65:498-500]
e dic u lo sis or phthiriasis oc curs in hu mans with poor per sonal hy giene or over crowded liv ing envi ron ment. Typically, Pediculus capitis is found in scalp hair; Pediculus corporis on the seams of clothing; and Phthirus pubis (crab louse) in the pu bic hairs. Rarely adult lice may iso lated in fest eye brows and eyelashes and cause phthiriasis palpebrarum. Phthiriasis palpebrarum in chil dren and ad o les cents has been described.1-4 Since the pubic louse dies quickly away from its host, trans mis sion is usu ally by close body con tact (es pe cially by sex ual con tact). Infants and chil dren are of ten in fested by di rect pas sage of the lice from the con tact with their par ent. In ter national com mu ni ca tion and sex ual free dom have increased the in ci dence of blepharoconjunctivitis due to
Phthirus pubis. It is, how ever, of ten misdiagnosed and undertreated be cause of the fail ure of phy si cians to rec og nize Phthirus pubis. Pres ented herein is a case of phthiriasis palpebrarum in an adult woman.
Case Report A 30-year-old woman re ported per sis tent left eye itch ing which was treated un suc cess fully with top i cal eyedrop at lo cal clinic for two weeks for al ler gic conjunc ti vi tis. She also re moved some egg sacs at tached to the eye lashes stalks from the eye lashes each morning. On ex am i na tion her vi sual acu ity was 6/6.7 in the right eye and 6/6 in the left. Slit-lamp ex am i na tion re-
Re ceived: September 14, 2001. Ac cepted: June 13, 2002. Cor re spon dence to: Chieh-Chih Tsai, MD, De part ment of Oph thal mol ogy, Tai pei Vet erans Gen eral Hos pi tal, 201, Sec. 2, Shih-Pai Road, Tai pei 112, Tai wan. Fax: +886-2-2555-1303; E-mail:
[email protected]
Oc to ber 2002
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their morphologic char ac ter is tics (Fig. 2). The pa tient was re ex am ined in a week to en sure that all of the parasites were re moved. The pa tient and her hus band were ad vised to avoid close body con tact un til comple tion of treat ment and fol low-up.
D iscussion
Fig. 1. The crab louse was noted over the cilia base of lid margin.
Fig. 2. Un der the light mi cros copy, the louse was iden tified to be a Phthirus pubis by its charac ter is tic crab-legged mor phol ogy, engorged with the pa tient’s blood. (Wet mount, 40).
vealed ev i dence of blepharoconjunctivitis with mul tiple red pin point ex cre tions over the left up per eye lid margin. With careful inspection, seven bugs (later proved to be the crab louse, Phthirus pubis) with numer ous trans lu cent oval eggs were noted around the base of the eye lashes (Fig. 1). No lice or nits were seen in the fel low eye or the other hairy ar eas. The patient de nied any his tory of ve ne real dis ease, louse infes ta tion else where in the body, or sex ual con tacts except her hus band who just came back from China. A man ual re moval of all the lice and the nits by the forceps was done care fully. Ex am i na tion un der light micros copy re vealed the bugs to be Phthirus pubis by
Adult lice in fest hairs of the scalp, axilla, chest, pu bic, rarely, eye brows and eye lashes. In fes ta tion of lice on eyebrows or eyelashes is most commonly caused by Phthirus pubis, rarely by Pediculus capitis, and never by Pediculus corporis.5 The trans fer ence to the eye is sup posed to achieve through the hand contact to the gen i tal area, which is per haps the rea son only one eye is af fected. Both eyes are in volved only when the du ra tion is pro longed. 6 Oc ca sionally, isolated palpebral involvement has been described. 1,4 The pubic louse can be identified as a 2 mm long, gray ish-white in sect (smaller than a body louse) with a dis tinc tively crab like ap pear ance (Fig. 2). The louse has three sets of legs with claws (Fig. 2), which are adapted for firm at tach ment to hair for suck ing blood. Four sets of small con i cal feet sup port the pos te rior abdomen and are involved in move ment. They lay seven to ten eggs (nits) per day. The in cu ba tion pe riod is usu ally be tween 5 days and sev eral weeks. The tiny, trans lu cent oval eggs are ce mented to the bases of the hair shafts and of ten con fused with the crusty flakes of seborrheic blepharitis. There may be ei ther no symptoms or itch due to hy per sen si tiv ity to the feed ing lice. Blepharitis with marked conjunctival in flam ma tion, preauricular lymphadenopathy and sec ond ary in fection at the site of lice bite may also oc cur. The clas sical blue spots, maculae caeruleae, may be seen on the in fected lid mar gins. Mar ginal keratitis pro duced by Phthirus pubis is rare. Di ag no sis is based on the finding of adult lice and/or eggs. Al though lice is hardly de tected be cause of semitransparency and deep burrow ing in the lid mar gin, phy si cians can find their slow move ment by care ful and pro longed ob ser vation. In spec tion of the ac cu mu la tion of trans lu cent oval nits and fe ces as red dish-brown gran u lar ma te rial on the base of the lashes may also help di ag no sis with
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the aid of slit lamp or mag ni fy ing lens/loupes. Ex am ina tion un der a low-power mi cro scope can con firm the char ac ter is tic mor phol ogy (Fig. 2) if nec es sary. It may also help trac ing back to the per sonal sex ual his tory and trav el ing his tory as in de tail as pos si ble. Nu mer ous in sec ti cide for mu la tions ap plied with cotton sticks have been suggested for phthiriasis palpebrum, including 1% aqueous malathion, physostigmine and pet ro la tum. 1,7 But some of these mo dal i ties suf fer from oc u lar or sys temic side ef fects or do not af fect the nits. Among other var i ous treatments rec om mended for phthiriasis palpebrum, mechanical removal with fine forceps is the most low-cost and ef fec tive one. Cryotherapy could damage both the lice and nits. 8 But the ther apy makes discom fort and may be dan ger ous for the un co op er a tive pa tients. The Ar gon la ser phototherapy can in stantly destroy the parasites and nits, though it may cause tem po rary loss of the treated eye lashes.9 All of these pro ce dures are lim ited by co op er a tion fac tors in children and may re quire an es the sia or se da tion. The treat ment of phthiriasis with 20% fluorescein eyedrops to kill the lice in sec onds has been re ported. 10 One per cent yel low ox ide of mer cury oint ment ap plied four times daily for 14 days have also shown to be safe and effective against lice and nits.11 Recently oral ivermectin has been tried. Be cause it has no ovicidal ac tiv ity, 2 doses of ivermectin, given a week apart, are re quired to erad i cate phthiriasis palpebrum.12 Ex am i na tion of the pa tient for other sites of in festa tion and a full screen for other sex u ally trans mit ted in fec tions should be un der taken, as 31.4% of the patients infested with Phthirus pubis are reported to have other sexually transmitted disease.13 Family mem bers, cur rent sex ual part ners and close com panies should also be ex am ined and treated. To pre vent reinfestation, sterilization of clothing, linens and groom ing in stru ments re quires a tem per a ture of 50 °C to kill all the lice and nits in 30 minutes. Patients should be re-examined for the ab sence of lice in the fol low ing week.
Chi nese Med i cal Jour nal (Taipei) Vol. 65 No. 10
In our case, me chan i cal re moval of all the lice and eggs was per formed me tic u lously with out any fur ther man age ment. The pa tient could stand well through the pro ce dure and no more lice or nit was found on the next visit. Though it is the most ef fec tive and cheap man age ment for phthiriasis palpebrarum, close follow-up for any re sid ual lice or nits is nec es sary. In con clu sion, this case re port tries to re mind the phy si cians, to be alert to phthiriasis palpebrarum even in a de vel oped coun try, in case of in trac ta ble blepharitis or con junc ti vi tis.
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