Bilateral acute keratouveitis in leptospirosis: a new entity.

Dear Editor,

A 25-year-old male presented with history of acute onset of redness, photophobia and decrease in vision in both eyes two days ago. On ocular examination, visual acuity was 20/60 both eyes. Anterior segment evaluation of both eyes revealed marked ciliary injection with acute central keratitis, 2x2 mm in size and minimal stromal edema of adjacent cornea. Slit-lamp examination showed fine keratitic precipitates with maximum concentration on the back of area of keratitis with preserved corneal sensation. Rest of the ocular examination was normal. He also had acute onset fever with severe generalized myalgia of three days′ duration. Systemic symptoms included proximal muscle weakness.

Based on systemic features leptospirosis was suspected by the physician and the diagnosis was established by positive IgM and IgG serology for anti-leptospiral antibodies. Other laboratory findings, which were also consistent with the diagnosis included proteinuria, raised erythrocyte sedimentation rate, leucocytosis and raised liver enzymes.

He was treated with intravenous ceftriaxone 1g twice daily for a week. Ocular treatment included topical 0.1% dexamethasone six times and 0.3% ciprofloxacin eight times daily. He responded well to treatment and was symptom-free in a week. Topical medications were stopped by the second week, however, macular grade opacity had formed at the area of keratitis.

Leptospirosis presents as a biphasic illness. The first phase is the septicemic phase characterized by nonspecific features like fever, headache, myalgia and conjunctival congestion, while the second phase is the immune phase.1

During the acute phase, which is due to active bacterial invasion, ocular manifestations include subconjunctival hemorrhage, retinal hemorrhage, papillitis, however uveitis does not manifest in the acute phase.2 While, in the immune phase, the ocular signs include acute non-granulomatous panuveitis, vasculitis.2,3 Corneal involvement in leptospirosis has been described only in one report, in the form of interstitial keratitis.1 In tropical countries leptospiral uveitis is one of the commonest causes of hypopyon uveitis along with ankylosing spondylitis and Behects disease.3

Leptospirosis is transmitted through human contact with surface waters or moist soil that harbors Leptospira interrogans.4 In our case, acute keratitis in both eyes can be due to direct inoculation of the organism on the cornea by contact with infected water. The presence of IgG anti-leptospira antibodies suggests that the patient might have been exposed to leptospira in the past and the repeat exposure had mounted the immune response, which was seen in the form of uveitis.

Treatment of systemic leptospirosis includes systemic penicillin, amoxycillin or ceftriaxone.5 The ocular inflammation was treated with low-dose topical steroids and antibiotics, in view of the presence of keratitis and acute phase of the disease.2,3

Acute keratouveitis is considered to be caused by the Herpes simplex virus unless proved otherwise.6 It can involve any corneal layer but is commonly associated with stromal keratitis which is usually diffuse but rarely can be sectoral.6 There is decreased corneal sensation and dendritic pattern corneal ulcer may also be present. However, Herpes zoster keratouveitis is differentiated by the associated dermatomal distribution of shingles. Interstitial keratitis is the commonest form of corneal involvement in keratouveitis and is associated with tuberculosis, leprosy and syphilis.7

Our patient had systemic features of leptospirosis without dendritic pattern of keratitis and preserved corneal sensations. There was no corneal vascularization to suggest interstitial keratitis. Leptospirosis has been known to cause acute epithelial keratitis in animals like horses etc. and an immunologic component has been suggested as a possible reason in their pathogenesis. The immunologic component cannot be ruled out in our case.8

In conclusion, leptospirosis can have diverse clinical presentations and a high degree of suspicion is required for its diagnosis. Letospiral keratouveitis is a relatively new clinical entity to be kept in mind in patients with systemic features.