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 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  Diagnosis and Tr...
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  Table of Contents  
Year : 2012  |  Volume : 30  |  Issue : 3  |  Page : 354-356

Case of Phthiriasis palpebrarum with blepheroconjunctivitis

1 Department of Microbiology, Sree Balaji Medical College and Hospital, Chrompet, Chennai-600 044, India
2 Department of Ophthalmology, Sree Balaji Medical College and Hospital, Chrompet, Chennai-600 044, India

Date of Submission23-Dec-2011
Date of Acceptance01-Apr-2012
Date of Web Publication8-Aug-2012

Correspondence Address:
B Kiran
Department of Microbiology, Sree Balaji Medical College and Hospital, Chrompet, Chennai-600 044
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.99504

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 ~ Abstract 

A 70-year-old woman came to ophthalmology outpatient department with complaints of repeated episodes of itching, redness and watering in both eyes of 3 months duration. She was treated with antibiotics elsewhere but had no improvement. Slit lamp examination showed lice and nits anchored to the eyelashes. Light microscopic examination of the matted eye lashes and crusts further helped in identification of the ectoparasites as Phthirus pubis (Pubic louse or Crab louse) with typical morphology.

Keywords: Phthiriasis palpebrarum, blepheroconjunctivitis, Phthirus pubis, ectoparasitic infestation

How to cite this article:
Kiran B, Kareem S A, Illamani V, Chitralekha S. Case of Phthiriasis palpebrarum with blepheroconjunctivitis. Indian J Med Microbiol 2012;30:354-6

How to cite this URL:
Kiran B, Kareem S A, Illamani V, Chitralekha S. Case of Phthiriasis palpebrarum with blepheroconjunctivitis. Indian J Med Microbiol [serial online] 2012 [cited 2020 Jul 3];30:354-6. Available from:

 ~ Introduction Top

Pubic lice infestation contributes 1-2% of total human population worldwide. In USA, it is about 2-10% especially in the sexually active age groups. [1],[2] Cases in India are under reported due to the social stigma attached. These commonly infest hair of pubic and perianal regions. In heavy infestations, they are found in hair of axilla, chest, eyebrows and eyelashes. [3],[4],[5] Mode of transfer to these areas is by hand after contact with the pubic region. Phthirus pubis (crab louse) infestation is generally associated with poor hygiene, overcrowding and is more common in the sexually active age group of 15-45 years. Route of spread is via sexual and close physical contacts in families. Infestation in children is not necessarily due to sexual abuse although this possibility should be kept in mind. Infestation by this parasite is regarded as a marker for other STD infections like HIV, syphilis, gonorrhoea, etc. [6],[7] We are presenting this case because of the unusual age group of the patient and rare site of infestation.

 ~ Case Report Top

A 70-year-old woman attended ophthalmic outpatient department with complaints of repeated episodes of itching, redness and watering in both eyes of 3 months duration. She was treated with local and systemic antibiotics before, with no relief of symptoms. Ocular examination revealed evidence of Blepheroconjunctivitis and immature cataract with visual acuity of 6/18. Slit lamp examination showed swollen eyelids covered with reddish brown crusts and ectoparasites resembling lice and nits.

After applying topical anaesthetic drops, the crusts were removed along with matted eyelashes and sent to the lab for microscopy. Examination of wet mount, under light microscope (10× objective lens) revealed live adult forms of P. pubis and their nits with typical morphology [Figure 1]. Gram Stain and KOH mount of the swabs taken from lid margins and conjunctiva did not show bacteria or fungi. Culture of these swabs on nutrient, blood and MacConkey agar plates showed no growth, after overnight incubation. Eyelashes were trimmed and local application of ciprofloxacin eye ointment twice daily given.She was advised to apply permethrin 1% to pubic and perianal regions. Oral Ivermectin 250 μg/kg stat was prescribed, followed by a repeat course of the same drugs after 10 days, to prevent nits developing into adult forms.
Figure 1: Microscopic view of the P. pubis under the light microscope (×10 objective)

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The patient was advised on treatment of close contacts, improvement of personal hygiene and various measures to prevent re-infection. She was referred to Skin/STD Clinic for further evaluation and asked to come for review after 2 weeks. On review, the patient showed dramatic improvement of her Blepheroconjunctivitis and her symptoms had subsided completely [Figure 2].
Figure 2: Patient showing improvement of blepheroconjunctivitis after delousing

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 ~ Discussion Top

Pthiriasis palpebrarum is generally the manifestation of Pthiriasis pubis which is now grouped under STDs. About 30% of cases are associated with other STD. [6],[7] It is an useful tool in forensic medicine, as in cases of rape and sexual abuse, the host DNA can be identified from the blood meal of the louse via PCR and Gene sequencing. [8],[9] Intense pruritis caused by the saliva of the louse (Immunologic reaction) lead to scratching, inflammation, eczema and superadded bacterial infection. The lice may carry Staphylococcus aureus and Streptococcus pyogenes on their surface and transmit these pathogens to humans. Sometimes small blue-grey spots (Maculae Ceruleae) are visible in louse bitten areas.

Phthirus pubis belongs to the phylum Arthropoda, the class Insecta, the order Phthiraptera. They are also called by other names like Pediculosis pubis, Pubic louse and Crab louse. The other two lice infesting man are Pediculus humanus capitis (head louse) and Pediculus humanus corporis (body louse). The body louse is the vector of typhus, trench fever and relapsing fever. Both are biological variants of the same species and have elongated body and narrow anterior mouthparts and they intermingle and interbreed. But P. pubis is entirely different species with a distinct morphology and habitat. Adult pubic louse is 1-2 mm in size with a wingless, broad and flat translucent body through which freshly injested blood meal can be visualized. The body is crab like and divided into head, thorax and abdomen. It has three pairs of short, stout legs and powerful claws which help to grasp tightly to hair shafts. Life span is around 1 month, passing through three stages: Nits to Nymph to Adult. Nits are operculated and are oval, white or dark and remain attached to the base of hair near the skin where they find right temperature to incubate. They are hard to remove. After 5-10 days, a nymph comes out and develops into adult in 7-10 days. Without a host, it cannot survive for more than 1 day.

 ~ Diagnosis and Treatment Top

Though easily seen by naked eye, confirmation is done by Light microscopy, Woods lamp or histological examination. [10] Pediculocide shampoo and creams like Malathion 0.5%, Permethrin 1%, Phenothrin 0.2% are used in Pediculosis pubis infestation in areas other than eyes. Several cases of resistance to topical treatment has been reported. [11],[12] Petrolatum jelly or inert ophthalmic ointment can be used for suffocating lice and its nits. Tab. Ivermectin is effective in killing these parasites by affecting the muscular and nervous system as it has a high affinity to glutamate-gated chloride channels. Phthiriasis palpebrarum can also be treated with argon laser therapy or cryotherapy. [13],[14]

This Ectoparasitic infestation is commonly misdiagnosed as bacterial, viral or allergic conjunctivitis or seborrhoeic dermatitis. Proper history taking and careful examination is a must for correct diagnosis and appropriate treatment.

 ~ References Top

1.Anderson AL, Chaney E. Pubic lice (Pthirus pubis): History, biology and treatment vs. knowledge and beliefs of US college students. Int J Environ Res Public Health 2009;6:592-600.  Back to cited text no. 1
2.Mimouni D, Ankol OE, Gdalevich M, Grotto I, Davidovitch N, Zangvil E. Seasonality trends of Pediculosis capitis and Phthirus pubis in a young adult population: Follow-up of 20 years. J Eur Acad Dermatol Venereol 2002;16:257-9.  Back to cited text no. 2
3.Manjunatha NP, Jayamanne GR, Desai SP, Moss TR, Lalik J, Woodland A. Pediculosis pubis: Presentation to ophthalmologist as pthriasis palpebrarum associated with corneal epithelial keratitis. Int J STD AIDS 2006;17:424-6.  Back to cited text no. 3
4.Rundle PA, Hunghes DS. Pthirus pubis infestation of the eyelids. Br J Ophthalmol 1993;77:815-6.  Back to cited text no. 4
5.Kincaid MC. Pthirus pubis infestation of the lashes. JAMA 1983;249-590.  Back to cited text no. 5
6.Varela JA, Otero L, Espinosa E, Sánchez C, Junquera ML, Vázquez F. Phthirus pubis in a sexually transmitted diseases unit: A study of 14 years. Sex Transm Dis 2003;30:292-6.  Back to cited text no. 6
7.Workowski KA, Berman SM. Ectoparasitic infections. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55:79-80.  Back to cited text no. 7
8.Mumcuoglu KY, Gallili N, Reshef A, Brauner P, Grant H. Use of human lice in forensic entomology. J Med Entomol 2004;41:803-6.  Back to cited text no. 8
9.Lord WD, Dizzino JA, Wilson MR, Budowle B, Taplin D, Meinkig TL. Isolation amplification and sequencing of human Mitochondrial DNA obtained from human crab louse, Pthirus pubis, blood meals. J Forensic Sci 1998;43;1097-100.  Back to cited text no. 9
10.Lopez GJ, Garcia LI, Martinez GJ. Pthiriasis palpebrarum; Diagnosis and treatment. Arch Soc Esp Oftalmol 2003;78;365-74.  Back to cited text no. 10
11.Vander Sticheler RH, Dezeure EM, Bogaert M. Systemic review of clinical efficacy of topical treatmentsfor head lic. BMJ 1995;311;604-8.  Back to cited text no. 11
12.Speare R, Koehler JM. A case of pubic lice resistant to pyrethrins. Aust Fam Physician 2001;30;572-4.  Back to cited text no. 12
13.Elston DM. Drugs used in the treatment of pediculosis. J Drugs Dermatol 2005;4:207-11.  Back to cited text no. 13
14.World Health Organization: Guidelines for the management of sexually transmitted infections. Geneva: WHO; 2003 (available from: /publications /rhr_01_10_mngt_stis/index.html) [Last accessed on 2011 Dec 08].  Back to cited text no. 14


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