AN 82-YEAR-OLD white woman was referred with a 3-week history of painful red right eye, right preauricular adenopathy, profound loss of visual acuity, and systemic manifestations of fever, malaise, and anorexia. There was no history of trauma and no notable medical history. She was treated by her ophthalmologist for herpes zoster infection without any response.
Visual acuity was counting fingers OD and 20/80 OS. There was no evidence of skin or scalp vesicles, but the right eyelids were erythematous. Right preauricular adenopathy was present. The corneal sensation was intact. Slitlamp examination showed a central corneal ulcer and 5% hypopyon (Figure 1 and Figure 2). The anterior chamber showed a brisk inflammatory reaction with fibrin. Discrete yellow conjunctival lesions were also noted (Figure 3). Conjunctival biopsy and multiple conjunctival and corneal cultures were performed. The biopsy specimen showed giant cells (Figure 4 and Figure 5) consistent with conjunctival granuloma.1 The presumptive diagnosis was Parinaud oculoglandular keratoconjunctivitis. All fungal and bacterial cultures were negative and a chest x-ray film showed no abnormalities. A serologic test for Francisella tularensis was strongly positive (1:320; >1:80 is significant). Further questioning of her daughter revealed that the patient had experienced a tick bite 4 to 5 days before her systemic symptoms began.
Steinemann TL, Sheikholeslami MR, Brown HH, Bradsher RW. Oculoglandular Tularemia. Arch Ophthalmol. 1999;117(1):132–133. doi:10.1001/archopht.117.1.132
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