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BRIEF COMMUNICATION
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 70-72

Unilateral phthiriasis palpebrarum infestation: An unusual case of pruritus


Department of Ophthalmology, Sagarmatha Choudhary Eye Hospital, Lahan, Siraha, Nepal

Date of Submission28-May-2019
Date of Decision28-Aug-2019
Date of Acceptance18-Nov-2019
Date of Web Publication2-Jul-2020

Correspondence Address:
Sabin Sahu
Sagarmatha Choudhary Eye Hospital, Lahan-3, Siraha
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_41_19

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  Abstract 


Phthiriasis palpebrarum is a rare cause of eyelid infestation caused by phthiriasis pubis (crab louse) that mainly infests the hair of pubis and inguinal regions, but rarely eyelashes and eyelid. It is an uncommon condition of pruritus still seen in developing countries with poor personal hygiene. These conditions may have unusual presentations which may be misdiagnosed as conjunctivitis, blepharoconjunctivitis, dermatitis, or blepharitis due to similarities in the signs and symptoms. We report a case of a young male with unilateral pruritus and irritation which showed numerous nits adherent to the eyelashes and multiple lice at the base of eyelashes at the upper lid on examination. The patient was successfully treated with mechanical removal of lice and nits, and pilocarpine 2% drop were applied locally. A typical case of unilateral phthiriasis palpebrarum infestation, which is an unusual case of pruritus, is highlighted. Meticulous examination with suspicion is essential for the prompt diagnosis and treatment.

Keywords: Crab louse, nits, phthiriasis palpebrarum, pruritus


How to cite this article:
Sahu S, Bhutia TW, Shrestha V, Kamble VK. Unilateral phthiriasis palpebrarum infestation: An unusual case of pruritus. J Clin Ophthalmol Res 2020;8:70-2

How to cite this URL:
Sahu S, Bhutia TW, Shrestha V, Kamble VK. Unilateral phthiriasis palpebrarum infestation: An unusual case of pruritus. J Clin Ophthalmol Res [serial online] 2020 [cited 2020 Aug 7];8:70-2. Available from: http://www.jcor.in/text.asp?2020/8/2/70/288844



Phthiriasis palpebrarum is a rare cause of eyelid infestation caused by phthiriasis pubis, commonly known as crab louse.[1] Phthiriasis pubis mainly infests the hair of pubis and inguinal regions, but rarely the eyelashes and eyelid. The condition is generally seen in developing countries and is associated with poor hygiene and overcrowding.[2] These conditions may sometimes be mistaken as blepharitis, blepharoconjunctivitis, allergic contact dermatitis, or seborrheic and rosacea blepharitis due to similarities in the signs and symptoms.[3] Various treatment options with varying efficacy are available.

We report a case of unilateral pthiriasis palpebrarum in a young male which was treated successfully with mechanical removal of the lice and nits on the eyelashes and local application of pilocarpine 2% drops in the lid margin.


  Case Report Top


A 16-year-old male presented to our outpatient department with symptoms of pruritus and irritation of the left eye for 1 week. On examination, visual acuity in both the eyes was 6/6. Slit-lamp examination of the left eye showed numerous, translucent, white nits adherent to the eyelashes and multiple mobile, semitransparent lice of different sizes at the base of eyelashes at the upper lid [Figure 1]. The lower eyelid was normal. No lice or nits were seen in the right eye. The pubis and inguinal regions were also examined where no signs of lice infestation were noted. The patient did not have any known systemic diseases. The patient was treated with mechanical removal of lice and nits with the use of forceps and was advised to apply pilocarpine 2% drops locally in the lid margin twice daily. The microscopic examination confirmed the lice to be phthiriasis pubis by their morphological characteristics [Figure 2]. The patient was followed up after a week to ensure that all of the parasites were removed [Figure 3]. No recurrence was seen in subsequent follow-up visits.


  Discussion Top


Phthiriasis palpebrarum is uncommon condition of pruritus still seen in developing countries with poor personal hygiene. Phthiriasis pubis or crab louse is an obligate ectoparasite which is found most commonly in the groin but can also occur in the axillae, chest hair, eyelashes, and eyebrow. Morphologically, adult lice are grayish white, 1/12 inch long, and oval in shape with abdomen broader than its length resembling a crab. Three pairs of legs are present in the thorax with thick, larger claws in two rear pairs, which allow improved grasp of hair shafts.[4] Isolated palpebral involvement has been described though it is usually associated with genital infestations.[1] In this case, the transference to the eye is probably through the hand contact to the genital area, which is perhaps the reason that only one eye is affected.

Patients usually present with symptoms of irritation, pruritus, visible lice, or nits, and on clinical examination, there may be blepharitis, conjunctival inflammation, preauricular lymphadenopathy, and infection at the site of lice bite.[5] The translucent oval nits and blood-tinged debris at the base of the eyelashes are often confused with crusty excretions of seborrheic blepharitis.[6] These conditions may have uncommon presentations which may be misdiagnosed as bacterial conjunctivitis, blepharoconjunctivitis, allergic contact dermatitis, or seborrheic and rosacea blepharitis due to similarities in the signs and symptoms.[3],[5],[6]
Figure 1: Before treatment: Multiple nits at the base of eyelashes in the upper eyelid (a). Enlarged view showing multiple nits and a crab louse at the cilia base of the lid margin (b)

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Figure 2: Under the light microscopy, the louse was identified to be phthiriasis pubis by its characteristic morphology (a) and a nit seen anchored to the eyelash (b)

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Figure 3: After treatment: Clear eyelashes and lid margin free from nits and lice (a). Enlarged view (b)

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There are multiple treatment options available for the treatment of phthiriasis palpebrarum. Manual removal of visible lice and nits is the standard therapy and can be done with forceps or eyelashes may be extracted in their entirety.[7] The simplest and safest therapy is cutting the eyelashes at their base in immediately removing the louse and the nits and the habitat essential for their survival with no cost for the patient in drugs and no ocular toxicity.[8] Other reported treatment modalities include application of 1% mercuric oxide, gamma-benzene hexachloride, white petrolatum ointment (Vaseline), topical 0.5% malathion solution or 1% shampoo, moxifloxacin ointment, oral ivermectin therapy (250 μg/kg; two doses given at 1 week interval), argon laser phototherapy, or cryotherapy.[4],[9] The safe and effective treatment using 4% pilocarpine gel has been reported though the exact mechanism of pilocarpine is unclear. It could be attributed to its direct cholinergic action of depolarizing the effector cell, causing paralysis of the lice, or because of direct pediculicidal action or even the smothering effect of the gel.[10],[11] The pilocarpine 2% eyedrop is commonly available, inexpensive, and approved for direct ocular use.

Ashraf et al. reported a case of unilateral phthiriasis palpebrarum in a 28-year-old male who was treated with moxifloxacin eye ointment and was completely cured in 1 week. In our case, we used 2% pilocarpine drops along with manual removal of lice and nits with forceps. The patient was completely cured and there was no recurrence in subsequent follow-up visits. The patient was educated regarding the mode of transmission of Phthiriasis palpebrarum. He was also advised to avoid interpersonal contact, personal clothes and fabrics be separated, washed properly and heat-dried to prevent the transmission.


  Conclusion Top


Phthiriasis palpebrarum is uncommon condition of pruritis still seen in developing countries with poor personal hygiene. Our case highlights a typical case of unilateral phthiriasis palpebrarum infestation, which is an unusual case of pruritus in the young age group. Meticulous examination under slit lamp with suspicion is essential for the prompt diagnosis and treatment of phthiriasis palpebrarum.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rundle PA, Hughes DS. Phthirus pubis infestation of the eyelids. Br J Ophthalmol 1993;77:815-6.  Back to cited text no. 1
    
2.
Ryan MF. Phthiriasis palpebrarum infection: A concern for child abuse. J Emerg Med 2014;46:e159-62.  Back to cited text no. 2
    
3.
Pinckney J 2nd, Cole P, Vadapalli SP, Rosen T. Phthiriasis palpebrarum: a common culprit with uncommon presentation. Dermatol Online J 2008;14:7.  Back to cited text no. 3
    
4.
Vijayalekshmi S. Phthiriasis palpebrarum. Our Dermatol Online 2012;3:355-7.  Back to cited text no. 4
    
5.
Couch JM, Green WR, Hirst LW, de la Cruz ZC. Diagnosing and treating Phthirus pubis palpebrarum. Surv Ophthalmol 1982;26:219-25.  Back to cited text no. 5
    
6.
Jiang J, Shen T, Hong CY. A peculiar case of eye pruritus: Phthiriasis palpebrarum initially misdiagnosed as common blepharitis. Int J Ophthalmol 2011;4:676-7.  Back to cited text no. 6
    
7.
Yoon KC, Park HY, Seo MS, Park YG. Mechanical treatment of phthiriasis palpebrarum. Korean J Ophthalmol 2003;17:71-3.  Back to cited text no. 7
    
8.
Mansour AM. Photo essay: Phthiriasis palpebrarum. Arch Ophthalmol 2000;118:1458-9.  Back to cited text no. 8
    
9.
Ashraf M, Waris A, Kumar A, Akhtar N. A case of unilateral phthiriasis palpebrarum infestation involving the left eye. BMJ Case Rep 2014;2014. pii: bcr2013203307.  Back to cited text no. 9
    
10.
Kumar N, Dong B, Jenkins C. Pubic lice effectively treated with Pilogel. Eye (Lond) 2003;17:538-9.  Back to cited text no. 10
    
11.
Oguz H, Kilic A. Eyelid infection. Ophthalmology 2006;113:1891.e1-3.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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