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Was That A Phthiriasis Palpebrarum Or A Tick Larva İnfested An Infant's Eyelid
MAKALE #10673 © Yazan Op.Dr.Serkan DAĞDELEN | Yayın Mart 2013 | 3,186 Okuyucu
We describe a case of Phthirus pubis infested both upper and lower eyelids of right and left eyes of a 4 year-old male infant. Parents brought the child to emergency ward because of insect bite on his back and unfortunately and accidentally they killed and removed the insect which was resembling to tick. Family was concerning about Crimean-Congo hemorrhagic fever . Parents saw the insect resembling to tick on the left eye of the child and applied to Near East University Medical Faculty Ophthalmology Department. Interestingly the larva and nymph stage of tick and lice are quite similar and can be misdiagnosed The child had redness and itching on both eyes for two weeks and they used some ophthalmic ointment and drops. The patient was successfully treated with mechanical removal of all lice and nymphs from the eyelashes under general anesthesia . In children, phthiriasis palpebrarum and tick infestation should be considered in the differential diagnosis of blepharoconjunctivitis that is resistant to treatment.

Introduction
Lice and ticks are parasites. Lice are small wingless insects that feed on dead skin or blood of hosts where as ticks are small arachnids that feed on the blood of mammals, birds and some reptiles. The life cycle of lice consists of three stages: nymph, nymph and adult, and the duration from egg to egg stage is about one month. Lice can last about one month on a person’s scalp. The life cycle of ticks consists of four stages: egg, larva, nymph and adult. (Fig. 1)
Tick infestation of eyelid is not common.(Fig. 2) The most frequent manifestations in
the eye are conjunctivitis, uveitis, keratitis and vasculitis.1 Tick inoculation of the skin can locally lead to granuloma and abscess formation. More concerning, however, is the potential systemic sequelae that can result from transmission of zoonoses such as Lyme disease, Rocky Mountain spotted fever, Crimean-Congo hemorrhagic fever, Ehrlichia, and tularemia.1-2 To avoid these complications, it is critical that the tick is completely removed.
Phthiriasis palpebrarum is caused by the Phthirus pubis, but the infestation of eyelashes is rare. It can cause pruritic eyelid margins or unusual blepharoconjunctivitis and, therefore, it is difficult to diagnose and treat.3-4 Eyelashes are sites of predilection for phthiriasis in children; We diagnosed and managed a case of phthiriasis palpebrarum in a 4 years old boy.
Especially the larva and nymph stage of tick and lice are quite similar and may lead to misdiagnosis and needs carefull biomicroscopic examination.

Case Report
The parents of a 4-year-old male infant applied to us with reports of itching and irritation of the left upper eyelid margin. Parents saw the insect resembling to tick on left eye of his son. Slit-lamp examination showed a reddened, crusty eyelid margin and hyperemic palpebral conjunctiva. He was unsuccessfully treated under the diagnosis of blepharoconjunctivitis. On careful ophthalmic examination, lice were detected at the base of the eyelashes, revealing multiple red pinpoint excretions and numerous small translucent oval nits coating the eyelashes (Fig. 3). Under magnification, each louse had three pairs of legs attached to the anterior portion of the abdomen, two antennae, and four pairs of small feet on the posterior portion of the abdomen . On dermatologic examination, there were no nits in his scalp hair. The patient was successfully treated with mechanical removal of all lice and nits from his eyelashes. Tobramycin ointment was applied on the eyelid margins to prevent secondary infection. At the examination two weeks after treatment, all lice were eradicated. The patient was treated according to the guidelines of the Declaration of Helsinki.

Discussion

Both ticks and lice can be encountered on eyelids . Although the differential diagnosis of tick larva stage and nymph stage or lice can easily be made on biomicroscopic examination, the larva and nymph stage of ticks are quite similar to lice and can be easily misdiagnosed at this stage of ticks.(Fig.4, Fig. 1)
Phthirus pubis is characterized by a separate head, thorax and abdomen, and three pairs of legs.(Fig. 4) Numerous small translucent nits coating the eyelashes can be seen easily. Ticks are chracterized by a fused head and thorax and four pairs of legs in adults. (Fig. 5) In our case on carefull biomicroscopic examination a seperate head thorax and abdomen and three pairs of legs were identified in contrast to the fused body and four pairs of legs of tick .
During tick attachment or after removal of the tick, abscesses may develop from secondary infection at the site of tick attachment. Additonally, granulomas may form after partial or even complete removal of the tick.6,5 In Phthirus pubis infestations no granulomas are encountered also in our case we did not observe any granulomas. Ticks are known to carry bacteria and produce salivary proteins responsible for several diseases in humans, including Rocky Mountain spotted fever, tularemia, Crimean-Congo hemorrhagic fever and toxin-mediated tick paralysis. All of these diseases can lead to serious systemic complications, including death, if not promptly and effectively treated.1,2,5
The symptoms associated with both phthiriasis palpebrarum and tick infestation range from pruritic eyelid margins to blepharitis with marked conjunctival inflammation.4,10 The signs of typical blepharoconjunctivitis and the presence of nits on the eyelashes is characteristic for the diagnosis of phthiriasis palpebrarum but in tick infestation it is impossible to see any nits on biomicroscopic examination which is also important for differential diagnosis. Lin et al.7 reported a case of a 30-year-old woman with persistent itching of the left eyelid that had been treated unsuccessfully under the diagnosis of allergic blepharoconjunctivitis. However, careful ophthalmic examination revealed numerous small translucent nits coating the eyelashes. The patient was successfully treated with mechanical removal of all of the lice and nits from the eyelashes. Our case had also been unsuccessfully treated under the diagnosis of bacterial conjunctivitis. Through careful ophthalmic examination, lice and nits were detected at the base of the eyelashes . In fact, eyelash contamination with phthirus pubis in children is secondary to contact with an adult carrier of a pubic phthiriasis.8 Infants and children with phthiriasis palpebrarum are usually infested by direct passage of the lice from the axillary or chest hair of the parents or by other infected contact.9 Charfi et al.8 presented four children with phthiriasis palpebrarum and discussed the ways of contamination of phtiriasis palpebrarum in children. The transmission can occur following sexual maltreatments or by means of infected clothing or bed linen. Yoon et al.4 diagnosed and managed a case of phthiriasis palpebrarum in a 6-year-old girl and removed the eyelashes, including the lice and nits, by pulling with fine forceps without sedation. They maintained that phthiriasis palpebrarum can be diagnosed by close examination of the eyelashes and eyelid margins with slit lamp and can be managed mechanically.
Keklikçi et al.10 diagnosed and managed a case of tick in a 3-year-old girl and The tick was completely removed with blunt forceps. She was treated with lid toilet, irrigation, and application of topical 0.3% ciprofloxacin four times daily to the affected eye. The lesion healed without scarring after one week. No systemic symptoms were observed. (Fig. 2)
In our case, there were no nits in the patient’s scalp hair on dermatologic examination. His parents denied any history of sexual contact or venereal disease. The treatments include anticholinesterase eye ointments, yellow oxide of mercury, or fluorescein. The simplest technique for the treatment of eyelid lice is direct removal of the lice and nymphs with fine forceps. Cryotherapy may provide a fast cure. Application of 1% gamma-benzene hexachloride cream and pyrethrin ointment are other options.3,4,9 In our case, mechanical removal of all lice and nymphs from the eyelashes was preferred. Diagnosis of phthiriasis palpebrarum is easy and requires the detection of the source of contamination to prevent reinfestations.
All methods of removal of ticks are directed toward complete elimination to prevent late complications. Removing ticks with forceps can be difficult and does not guarantee that all parts of the tick will be removed. The anesthetic property in tick saliva may inhibit host awareness of the bite. Additionally, these ticks, when engorged with blood, can be deceptive in their appearance and may resemble a pigmented growth. To avoid potential late complications and development of infectious diseases, clinicians should 1) be able to recognize these cases; 2) ensure complete removal of the organism and consider en bloc excision when infestation is in a conducive location such as the eyelid; 3) obtain serology to check for zoonoses; and 4) emphasize the importance of prevention to patients by encouraging the use of protective clothing and repellent for skin and clothing.
Ophthalmologists must be aware of resemblence of tick (larva and nymphs) and lice and must keep in mind that especially tick infestation may cause even fatal complications. In children, phthiriasis palpebrarum and tick infestation should be considered in the differential diagnosis of blepharoconjunctivitis that is resistant to treatment.
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