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CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 880-881

Rare presentation of toxic endothelitis because of mustard seeds and insect toxin


1 Department of Ophthalmology, Base Hospital Delhi Cantt, New Delhi, India
2 Department of Ophthalmology, Armed Forces Clinic, New Delhi, India
3 Cornea and Anterior Segment Services, Department of Ophthalmology, Army Hospital (Research and Referral), New Delhi, India

Date of Submission13-Jul-2022
Date of Acceptance10-Aug-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Anchal Tripathi
Department of Ophthalmology, Base Hospital Delhi Cantt, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1717_22

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  Abstract 


Mustard seeds have been reported to cause contact dermatitis and even second-degree burns over the exposed skin. However, there have been no previous case reports on mustard seed-induced toxic endotheliitis. Mustard seeds have toxic compounds such as glycosides. There have been few reports on insect sting causing ocular changes. However, there have been no case reports on toxic endotheliitis caused because of rubbing of the eye containing a small insect. We report two such cases of toxic endotheliitis with rare presentation. Both the cases presented with intense photophobia and blurred vision in the affected eyes. The first case had a history of rubbing of an insect inside the eye. The other case had a history of husking mustard harvest a few hours prior to the occurrence of symptoms.

Keywords: Glycosides, insect toxin, mustard seeds, toxic endotheliitis


How to cite this article:
Tripathi A, Vats S, Sati A, Goenka R. Rare presentation of toxic endothelitis because of mustard seeds and insect toxin. Indian J Ophthalmol Case Rep 2022;2:880-1

How to cite this URL:
Tripathi A, Vats S, Sati A, Goenka R. Rare presentation of toxic endothelitis because of mustard seeds and insect toxin. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Dec 5];2:880-1. Available from: https://www.ijoreports.in/text.asp?2022/2/4/880/358157



Endothelial cells are a single layer of cells lining the posterior surface of Descemet's membrane of the cornea.[1] The function of these cells is to maintain the transparency of the cornea with the help of the sodium–potassium adenosine triphosphatase (Na+/K+-ATPase) pump, present in the basolateral surface of these cells.[1] Dysfunction of this pump leads to corneal edema.[1]

Toxic endotheliitis is a sub-class of corneal endotheliitis. Endotheliitis, in turn, is a term used to define the inflammation of the corneal endothelium. It can occur because of varied etiological factors, such as the cases of cataract surgery or refractive surgeries post-operatively, viruses such as herpes, and certain toxins.[2] The clinical features include the presence of corneal edema and keratin precipitates (KPs) with or without uveitis.[2]

We report two such cases of toxic endotheliitis with rare presentation. Both the cases presented with intense photophobia and blurred vision in the affected eyes. The first case had a history of rubbing of the insect inside the eye. The other case had a history of husking mustard harvest a few hours prior to the occurrence of symptoms, seeds of which allegedly also went inside both the eyes.


  Case Reports Top


Case 1

A 36-year-old female, with no known co-morbidities, presented with 1 day history of intense photophobia and blurred vision in the left eye. It was also associated with redness, watering, and burning sensation in the said eye. The patient had a history of falling of the insect inside the eye, followed by rubbing of the eye. The patient experienced intense photophobia and watering in the left eye the next morning. On washing her eye with plain water, she could allegedly remove parts of a dead insect from her eye. On examination, the best spectacle corrected visual acuity (BSCVA) in her left eye was found to be 20/60. Slit lamp examination revealed grade 3 conjunctival injection, Descemet's folds in the cornea, and 1+ flare in the anterior chamber with occasional cells. There was no corneal epithelial defect. Intra-ocular pressures were normal. Left eye fundus was grossly normal. Right eye ophthalmic examination was unremarkable. A diagnosis of toxic endotheliitis was made for the left eye, and the patient was kept on topical steroids, cycloplegics, and lubricants. The patient improved completely in 1 week after treatment, and the BSCVA also improved to 20/20.

Case 2

A 70-year-old male, a known case of type 2 diabetes mellitus (on treatment), presented with complaints of redness, intense photophobia, blurred vision, and watering in both the eyes since 1 day. The patient had a history of husking his mustard harvest 3 hours prior to the occurrence of the symptoms. Allegedly, a few mustard seeds went inside both his eyes while husking them, followed by which he washed his eyes thoroughly with plain water. Examination of the right eye showed 20/80 BSCVA, whereas the left eye had 20/40 BSCVA. Peri-ocular erythema along with edema was observed with oculus uterque (OU) [Figure 1]a. On slit lamp examination, the right eye was found to have grade 4 conjunctival congestion, Descemet's folds in the cornea associated with slight stromal haze in the surrounding area, and 2+ flare with occasional cells in the anterior chamber [Figure 1]b. Examination of the left eye revealed grade 3 conjunctival congestion, mild stromal haze in the cornea, and 1+ flare with occasional cells in the anterior chamber [Figure 1]c. No epithelial defect in the cornea was found. Intra-ocular pressures were normal. Bilateral fundus examination was within normal limits. A diagnosis of bilateral eyelid contact dermatitis with toxic endotheliitis was made. Thorough eye wash was performed for both the eyes. The patient was given intravenous injection hydrocortisone 100 mg stat along with injection avil 25 mg stat to suppress hyper-sensitivity reaction. He was kept on topical steroids, cycloplegics, and lubricants along with an oral anti-allergic (levocetrizine). The patient was completely relieved of his symptoms in 10 days [Figure 1]d and [Figure 1]e. The vision of both eyes was restored to 20/20.
Figure 1: (a) Severe contact dermatitis on day 1; (b) Descemet's folds and anterior chamber reaction in the right eye on day 1; (c) few Descemet's folds on the inferior cornea of the left eye and mild anterior chamber reaction on day 1; (d) right eye after 1 week of treatment; (e) left eye after 1 week of treatment

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  Discussion Top


We report two rare presentations of toxic endotheliitis. To our knowledge, this is the first such case report. Our first case presented with toxic endotheliitis because of rubbing of the insect in the eye. She had no epithelial defect. Her symptoms appeared the next day of the incident of the insect falling in her eye. Many insect species release certain toxin compounds, which can cause immunological reaction in the corneal endothelium.[3],[4] Yildrim et al.[5] reported a case of bee sting of the cornea, where immune reaction around the stinger led to corneal damage.

Our second case had a history of mustard seeds in his eyes. Mustard seeds have sulfur-containing chemicals, known as glucosinolates.[6] These glycosides are known to penetrate the intact epithelium and inhibit endothelial Na+/K+-ATPase, thereby damaging the corneal endothelium.[6] Amiran et al.[7] and Chakraborty et al.[1] reported milder cases of corneal endotheliitis because of exposure to plant sap of milky latex. Milky latex is known to contain cardenolides, which cause temporary damage to corneal endothelial cells.[7]

Both the cases presented with severe photophobia, redness, pain, watering, and blurring of vision in the affected eye, all because of intense inflammation. Therefore, both the patients were prescribed topical steroids on an hourly basis in order to reduce inflammation. Also, Hatou et al.[8] demonstrated in their study that dexamethasone increases Na+/K+-ATPase pump activity in cultured corneal endothelial cells.

Both the cases showed improvement with the given treatment within 1 week, and there was complete resolution of the signs and symptoms.

Toxic endotheliitis can be caused because of a variety of etiological agents. Identifying the agent and prompt treatment is imperative.


  Conclusion Top


Toxic endotheliitis can be caused by a number of etiological agents. There have been numerous case reports on toxic endotheliitis because of bee stings and plant sap, as discussed above. However, to the best of our knowledge, there is no case report on toxic endotheliitis because of mustard seeds or insect toxins. Our case report provides insight to such presentation and its management strategy. Having a low threshold for starting topical steroids is the key in managing such cases. Permanent vision loss may occur if treatment is delayed in such cases with severe presentation.

Author contribution

All authors fulfil the ICJME authorship criteria

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.
Chakraborty S, Siegenthaler J, Buchi ER. Corneal edema due to Asclepias curassavica. Arch Ophthalmol 1995;113:974-5.  Back to cited text no. 1
    
2.
Suzuki T, Ohashi Y. Corneal endotheliitis. Semin Ophthalmol 2008;23:235-40.  Back to cited text no. 2
    
3.
Villada JR, Panos MI, Del Cerro I, Granados JM. Ocular injury caused by the bombardier beetle. Case Rep Ophthalmol 2021;12:629-33.  Back to cited text no. 3
    
4.
Nikbakhtzadeh MR, Tirgari S. Medically important beetles (insecta: Coleoptera) of Iran. J Venomous Anim Toxins Incl Trop Dis 2008;14:4597-618.  Back to cited text no. 4
    
5.
Yildrim N, Erol N, Basmak H. Bee sting of the cornea: A case report. Cornea 1998;17:333-4.  Back to cited text no. 5
    
6.
Lietzow J. Biologically active compounds in mustard seeds: A toxicological perspective. Foods 2021;10:2089. doi: 10.3390/foods10092089.  Back to cited text no. 6
    
7.
Amiran M, Lang Y, Yeung S. Corneal endothelial toxicity secondary to Asclepias fruticosa. Eye 2011;25:961-3.  Back to cited text no. 7
    
8.
Hatou S, Yamada M, Mochizuki H, Shiraishi A, Joko T, Nishida T. The effects of dexamethasone on the Na, K-ATPase activity and pump function of corneal endothelial cells. Curr Eye Res 2009;34:347-54.  Back to cited text no. 8
    


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