Fungal lesions on the eyelids

Aspergillosis of the eyelid manifests itself as a massive, granuloma-like node with a tendency to ulcerate and form fistulas, which can be mistaken for a suppurating chalazion.

Nodes similar to aspergillosis in clinical signs are sometimes observed in the localized lymphatic form of sporotrichosis of the eyelids. However, sporotrichosis most often forms slowly enlarging inflammatory nodules under the skin, mainly of the ciliary edge of the affected eyelid (subcutaneous form). Merging, they are penetrated by fistulous tracts, ulcerate and then, according to H. Heidenreich (1975), resemble gummas or colliquative tuberculosis. Regional lymph nodes are enlarged, but painless. The course of the disease is chronic. Eye diseases are almost always preceded by siotricosis of the oral mucosa, where the fungi are brought from plants on which they saprophyte. Using blades of grass instead of a toothpick, biting them or chewing them leads to such mycosis.

Eyebrows and eyelashes are susceptible to favus (scab), which usually develops in patients with favus of the scalp and, much less often, as a disease of the eyelids only. Against the background of hyperemic skin in the area of the eyebrows and the ciliary edge of the eyelids, small vesicles and pustules appear, followed by the formation of yellowish saucer-shaped crusts - scutulae (shields). In the center of such a crust there is a hair or eyelash, thin, fragile, covered with a coating. When trying to remove the scutula, the skin underneath bleeds, and after healing, scars remain; on the eyelids, however, they are barely noticeable. Scutulae, like the yellowish dots around the eyelashes that precede them, consist of fungal masses.

Superficial trichophytosis (ringworm) of the eyelids caused by anthropophilic species of trichophyton manifests itself mainly on their smooth skin as pinkish rounded lesions ("plaques"), the edges of which are raised in a ridge covered with nodules, pustules and crusts ("border"), and the center is pale and flaky. The disease is often acute; with rational treatment, its lesions can be eliminated in 9-12 days. In the chronic course, long-term therapy is required. The ciliary edges of the eyelids are very rarely affected by trichophytosis. Only a few cases of "trichophytosis purulent blepharitis" are described in the literature. Trichophytosis of the eyebrow area with damage to their hair is possible.

In deep trichophytosis of the eyelids caused by zoophilic trichophytons, an infiltrative-suppurative process develops in the form of follicular abscesses. H. Heidenreich describes them as soft, red, crusted and fistulous growths similar to granulations, leaving scars after healing.

Trichophytosis most often affects school-age children, who are affected by the scalp, smooth skin, and nails. Women account for 80% of patients with chronic trichophytosis. Trichophytosis of the eyelids, as a rule, develops against the background of a general lesion. The features of its clinical picture, the detection of the pathogen, often detected by microscopy of hair, especially vellus, a positive reaction with trichophytin facilitate the recognition of the disease.

Very severe eyelid lesions are caused by actinomycetes radiant fungi. The process is often secondary, spreading to the eye area from the oral cavity (carious teeth). The pathological focus affects not only the eyelids, but also the forehead, temple, and the edema extends to the entire half of the face. Against the background of edema, more pronounced at the outer corner of the eye slit, an extensive granuloma is formed, the suppuration of which leads to the appearance of fistulas with thick purulent discharge containing yellowish grains (fungal druses). Without treatment, healing granulomas are replaced by new ones. The process can spread to the orbit or, conversely, from the orbit to the eyelids.

In addition to direct damage by fungi, allergic processes caused by these irritants are possible on the skin of the eyelids. As E. Fayer (1966) points out, eyelid diseases that are poorly responsive to antibacterial and other therapy are suspicious of fungal allergy. The probability of allergy increases in patients with foci of chronic fungal infection. It was noted above that the allergic nature of eyelid damage associated with fungi confirms its rapid (even without local therapy) recovery after the elimination of fungal foci. These diseases manifest themselves in the form of fungal-allergic blepharoconjunctivitis or eyelid eczema. The first disease has no noticeable symptoms that would distinguish it from banal blepharitis; more often, only the conjunctiva is affected. Fungal-allergic eyelid eczema is more often observed in women, and its initial foci, according to E. Fayer, are vaginal mycoses. Less common foci are budding fungi hidden under dentures and dental bridges in the oral cavity, sometimes "interdigital itch", chronic mycoses of the feet and nails. Clinically, such eczema is characterized by swelling of the eyelids, hyperemia, peeling, itching, brown-red coloration of the skin. Patients have positive tests with fungal antigens. The disease is most often caused by fungi of the genus Candida, sometimes trichophytons.

The literature also describes individual observations of the development of blastomycosis, mucormycosis, rhinosporiosis and other fungal infections on the eyelids.

Fungal diseases of the lacrimal ducts are most often manifested by canaliculitis, which occurs with hyperemia of the conjunctiva in the area of the lacrimal canals, lacrimation disorders, and discharge of pus from the canal. The content of grains or crumbs in the latter is suspicious for mycosis, while the expansion of the canal in some area, the formation of a chalazion or barley-like calculus here, and when extracted, a gray or yellowish calculus up to the size of a grain of rice almost always indicates a fungal infection, which is confirmed by laboratory testing.

Concrements are formed by aspergilli, penicillium, trichophyton, actinomycetes and other fungi.

The introduction of fungi into the lacrimal sac leads to its chronic inflammation. To diagnose fungal dacryocystitis, a systematic study of the contents of the sac entering through the lacrimal ducts or the material obtained during dacryocystorhinostomy or melanoma extirpation is required for fungi.

It is possible that fungal infection is one of the causes of relapses of dacryocystitis after its surgical treatment.

Fungal conjunctivitis is probably more often overlooked than diagnosed, since it often occurs against the background of mycoses of the eyelids or cornea and in such cases is assessed as a concomitant irritation of the conjunctiva. Only more pronounced hyperemia and edema of the conjunctiva, detection of inclusions in it similar to grains or infarctions of the meibomian glands, or growths similar to granulations, as well as the ineffectiveness of antibacterial and other therapy make one think about mycosis of the conjunctiva. Fungi can be detected in such patients by examining stones and granulations, less often smears and scrapings.

The noted changes are characteristic of sporotrichosis, rhinosporidiasis, actinomycosis, coccidioidomycosis of the conjunctiva, while penicillium causes the formation of ulcers with a greenish-yellow coating on its surface (Pennicillium viridans), with coccidioidomycosis, phlyctenoid formations can be observed, and pseudomembranous conjunctivitis is characteristic of candidiasis, aspergillosis and other fungi. In some cases, fungal conjunctivitis occurring with the formation of nodes is accompanied by a pronounced reaction of the lymph nodes, causing diseases similar to Parinaud's syndrome, and the lymph nodes can suppurate, the pus can contain fungi. Conjunctival cephalosporiosis occurs as bilateral blepharoconjunctivitis with small erosions and ulcers of the conjunctiva and cornea, and sometimes with concretions ("plugs") in the lacrimal canals. Candida albicans, less often penicillium, aspergillus and mucor, producing antigens in extraocular foci, cause the development of fungal allergic conjunctivitis.

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Risk factors

Infection with specific infectious mycoses, including especially dangerous fungal infections (histoplasmosis, blastomycosis, mold mycoses), is accompanied by pronounced sensitization. Fungal eye infections are common in various situations accompanied by suppression of cellular immunity.

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Pathogenesis

Superficial and deep palpebromycoses can be caused by essentially any pathogenic and opportunistic fungi for humans, often moving from the eyelids to the conjunctiva and eyeball, penetrating into the orbit, although their reverse spread is also possible. More often than other mycoses, eyelid lesions of Candida albicans occur. This yeast-like fungus is brought into the eye area from the soil, transmitted from person to person, or comes from primary foci of candidiasis in the cavities of the mouth, nose, conjunctiva. When infected and with reduced resistance of the body, a disease occurs that manifests itself as inflammatory hyperemia and edema of the skin of the eyelids, sometimes pasty edema. Against the background of hyperemia and edema, small pustules are formed, and in the thickness of the eyelids, reddish-brown nodes similar to barley or chalazion, prone to ulceration, are formed. More often, such nodes are observed in patients who have had a long history of antibiotics before mycosis. The pathogen is found in the purulent contents of the nodes.

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Symptoms fungal lesions on the eyelids

Common severe mycoses are described, the entry point for which was the conjunctiva.

Actinomycosis, the most common fungal eye infection, is caused by actinomycetes, a fungus similar in its properties to anaerobic bacteria. Actinomycetes are widespread in nature: in the air, on plants, and in humans on the skin, mucous membranes, in carious teeth, and in the intestines.

Skin lesions of the eyelids may be primary, exogenous, and secondary as a result of fungal metastasis to the skin from foci in internal organs. Actinomycosis of the eyelids is characterized by the appearance of dense, painless nodules, later deep infiltrates, surrounded for some distance by skin of a woody consistency. The nodules soften in the center and open up, fistula openings appear on the infiltrates, from which pus containing fungal threads is released. Fistulas are long-term non-healing.

Aspergillosis is caused by a mold fungus that often lives asymptomatically on healthy skin and mucous membranes. In its clinical course, aspergillosis resembles tuberculosis.

Blastomycosis. Blastomycosis is caused by various yeast-like fungi that live in the soil, in places where pigeons nest, in barns, and stables. They are present on the skin and mucous membranes, in the urine and excrement of people and animals with this mycosis. In the clinic, deep systemic lesions of the visual organ predominate - usually secondary phenomena.

The lesion may be isolated or combined with candidiasis of the skin. Papules, erosions, ulcers appear on the skin of the eyelids, the surface is moist, slightly moist, the ulcers are covered with a white or yellowish coating. Itching is disturbing. Papules and ulcers sometimes spread across the face. The disease may be accompanied by deformation of the edges of the eyelids and eversion of the eyelids. The course is often long-term, chronic.

Histoplasmosis is a systemic deep mycosis that primarily affects the reticuloendothelial tissue, in the cells of which small yeast-like elements of the fungus - mycoplasma - accumulate.

Candidiasis is caused by yeast-like fungi that are found on fruits, vegetables, fruits and other products in stagnant waters, on the skin and in the gastrointestinal tract of both healthy and sick people and animals. Eye lesions may be isolated or combined with candidiasis of the skin, mucous membranes, internal organs (especially the digestive tract and lungs) or with generalized candidiasis. Combined lesions are possible - microbial and fungal.

Mucorosis is caused by fungi that are widespread in the environment and are often found on vegetables, fruits, hay, and cotton. The mucous membranes of the mouth, respiratory tract, genitals, and digestive tract are most often affected. Orbital and, less commonly, corneal lesions are secondary.

Rhinosporidiasis is a rare deep mycosis, the causative agent of which is poorly understood. The disease manifests itself as pollinous and pollinous-ulcerous formations on the mucous membrane of the nose, nasopharynx, conjunctiva, eyelid, and in the lacrimal sac.

Sporotrichosis is caused by filamentous fungi - sporotrichum. The source of infection is soil, some plants, grass, as well as sick people and animals. This is a deep, chronic mycosis, affecting mainly the skin, subcutaneous tissue, often the eyelids and conjunctiva. Typically, the skin of the eyelids is affected in the form of dense, painless, slowly growing nodes. The skin above them is purple. Over time, the nodes soften, fistulas are formed, from which yellow-gray pus is released.

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Diagnostics fungal lesions on the eyelids

Diagnosis requires isolation of the pathogen.

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Treatment fungal lesions on the eyelids

Candidomycosis of the eyelids is treated by lubricating the lesions with brilliant green, prescribing nystatin or levorin orally, using them locally in the form of ointments, creams, and lotions on eye bases. Solutions of nystatin and amphotericin B are instilled into the conjunctival sac.

Treatment of eyelid aspergillosis is carried out locally and intravenously with amphotericin B, amphoglucamine is given orally, and fungicidal ointments are applied locally.

In case of sporotrichosis of the eyelids, the best effect is given by iodine preparations, in particular potassium iodide, administered orally at 3-6 g daily for 4-5 months. Nystatin, levorin, and amphotericin B have also been tested with positive results.

Griseofulvin, administered orally, is effective for favus. The skin in the eyebrow and eyelash area is lubricated with 0.5-1% copper sulfate ointment or 1% yellow mercury ointment, or in the morning the lesions are lubricated with 3-5% alcohol iodine solution, and at night the ointments are applied and lightly rubbed in.

For the treatment of trichophytosis of the eyelids, griseofulvin is used orally at a rate of 15 mg per 1 kg of body weight, of course, in the absence of contraindications. The drug is given daily until the first negative result of the study of fungi of hair and scales, then for 2 weeks the patient takes the same daily dose every other day and for another 2 weeks every 2 days on the third. At the same time, local iodine ointment therapy: the lesions are lubricated with 5% iodine tincture, and in the evening with ointments containing sulfur. Lotions from 0.25% and 0.5% silver nitrate solution, ethacridine lactate (rivanol) solution 1: 1000 are recommended. Eyebrows should be trimmed, and eyelashes should be epilated. Due to the possibility of layering of pyogenic flora, sulfonamides are used at the beginning of treatment for 5-7 days.

Actinomycosis of the eyelids, unlike other fungal diseases, is treated with the most common antibiotics and sulfonamides. Penicillin is prescribed parenterally in high doses for 6 weeks or more, or tetracycline, erythromycin, broad-spectrum antibiotics, which give the best effect. The cavities of abscesses are washed with solutions of the same agents. Sulfonamides are prescribed instead of antibiotics if the latter are insufficiently effective. Potassium iodide is recommended for internal use. The specifics of the therapy confirm the validity of classifying actinomycete lesions not as true, but as pseudomycoses.

In the treatment of fungal-allergic eyelid eczemas, the main thing is the sanitation of extraocular foci of mycosis, and, if indicated, the fight against secondary infection, the administration of general desensitizing agents, and specific desensitization with fungal antigens.

Fungal canaliculitis is quickly cured by dissecting the affected canals along their length and removing the fungal masses (scraping). Less often, additional cauterization of the dissected canal with an alcohol solution of iodine or silver nitrate is required.