Keratoconjunctivitis sicca during folicular conjunctivitis in adult patients with Chlamydia pneumoniae etiology (summarizing twelve years study)

AIM: Following the previous study observing keratoconjunctivitis sicca (KCS) after treated follicular conjunctivitis of chlamydial etiology from the years 1999-2002, at this time the authors would like to point out the possible connection between KCS appearance and Chlamydia pneumoniae infection. MATERIAL: In the Department of Ophthalmology, during the period of 12 months (in the years 2009 - 2010), there were treated 11 adult patients (6 women and 5 men) in the age of 28 - 81 years (median, 50 years) with follicular conjunctivitis lasting on average 2.5 years and caused by Chlamydia pneumoniae, and simultaneously were diagnosed the symptoms of KCS, out of the total number of 37 examined patients with similar clinical findings. METHODS: The diagnosis of chlamydial infection in clinical symptoms of follicular conjunctivitis and simultaneous signs of KCS was established partly according to the serologic positivity of chlamydial genus (anti-LPS) and/or species (anti-Ch. pneumoniae and anti-Ch. trachomatis) IgG, IgM, and IgA antibodies together with simultaneous anti-cHSP60 IgG positivity, further using conjunctival prints examined by means of indirect immunofluorescence method using specific monoclonal antibodies; in conjunctival smears and peripheral leucocytes was tested also the presence of Chlamydia pneumoniae DNA. The main subjective complaints of the patients were burning sensation, sticking, or foreign-body sensation; the itching and lacrimation were less common. Among clinical signs dominated the hyperemia and the edema of the lower fornix; the tortuosity of the vessels and the follicles were not always present. The KCS diagnosis was confirmed by Bengal rose staining. RESULTS: In 10 patients, the positive IgA and/or IgM anti-Ch. pneumoniae antibodies were detected. Simultaneously, the positive anti-cHSP60 IgG were confirmed, out of them medium- and high-positive findings were in 7 patients, and anti-LSP antibodies IgA and/or IgM in 8 of them. Positive smears were found in 6 patients. In 2 persons of this group of treated patients, the general serologic findings were not significant, but the Chlamydia pneumoniae infection was confirmed by Chlamydia pneumoniae DNA positivity in peripheral leucocytes; in these 2 patients, the symptoms lasted for one half of the year. As the side findings were the confirmations of active Chlamydia trachomatis infection in other 4 patients of the whole group. The patients with Chlamydia pneumoniae infection were treated systemically by macrolide antibiotic azithromycine for 12 days. After the treatment, above all else the clinical signs of conjunctival inflammation disappeared, but remained KCS symptoms, which were disappearing only slowly. The optimal supporting therapies were lubricant drops with different concentration of sodium hyaluronide without preservatives. Control microbiological examinations during 6 months after the treatment termination confirmed negative smears findings, but the antibody levels were not decreased significantly. CONCLUSION: This study confirmed the possible connection between the KCS and Chlamydia pneumoniae infection in simultaneous clinical signs of follicular conjunctivitis. Along with that the study pointed out the necessity of simultaneous evaluating of the microbial findings and clinical symptoms to consider the systemic antibiotic treatment.