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Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 80-82

Bug alert! A case report and review of literature on bilateral phthiriasis palpebrarum

Department of Ophthalmology, C. H. Nagri Eye Hospital, Ahmedabad, Gujarat, India

Date of Submission23-May-2021
Date of Decision20-Nov-2021
Date of Acceptance23-Nov-2021
Date of Web Publication18-Jul-2022

Correspondence Address:
Shivani H Patel
Department of Ophthalmology, C. H. Nagri Eye Hospital, Ellis Bridge, Ahmedabad - 380 006, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcor.jcor_77_21

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We report a case of phthiriasis palpebrarum in an immunocompetent individual along with the review of the literature. A 61-year-old woman presented with a 2-month history of itching and burning sensation in both eyes. Examination revealed lice and nits anchored to the eyelashes with a mild follicular conjunctival reaction and no evidence of discharge. The patient recovered fully within 2 weeks after manual removal of the lice and crusts along with topical antibiotic ointment and oral ivermectin, with no evidence of lice or nits on follow-up. This study suggests that patients presenting with itching of the eyelids and other asthenopic symptoms should be carefully examined by slit-lamp examination, to not miss out on unusual diagnoses such as found in this case.

Keywords: Blepharitis, lice, phthiriasis, pruritis, slit-lamp examination

How to cite this article:
Patel SH, Shah AV, Singh S, Purohit D, Patel R, Hindocha S. Bug alert! A case report and review of literature on bilateral phthiriasis palpebrarum. J Clin Ophthalmol Res 2022;10:80-2

How to cite this URL:
Patel SH, Shah AV, Singh S, Purohit D, Patel R, Hindocha S. Bug alert! A case report and review of literature on bilateral phthiriasis palpebrarum. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Mar 24];10:80-2. Available from: https://www.jcor.in/text.asp?2022/10/2/80/351299

  Introduction Top

Phthiriasis palpebrarum is a type of ocular lid infestation caused by an ectoparasite, Phthirus pubis (crab louse), which usually infests hair of the pubic region. Lice may be transferred from one hair-bearing area to another, and any hair-bearing area may become infested.[1] However, it rarely involves the eyelashes or eyelids, which is known as phthiriasis palpebrarum.[2] Phthiriasis palpebrarum is rarely reported in the literature, as perhaps it is being missed due to its clinical similarity with anterior blepharitis.[3] The condition is generally seen in developing countries and is associated with poor hygiene and overcrowding.[4] Clinically, it presents as itching, erythema, discolouration of the skin as dark brown or red spots, adult lice and nits appearing as white flakes, excoriation of the eyelid skin, conjunctivitis and rarely keratitis.[5] These symptoms can easily be overlooked by clinicians labeling the patients with a misdiagnosis of anterior blepharitis, perhaps being the reason for less reported cases.[6]

  Case Report Top

A 61-year-old, patient presented to our outpatient department with symptoms of pruritus and irritation of both eyes for 2 months. She had initially visited another institute at the onset of symptoms where she was given subjective correction and prescribed glasses. Due to nonimprovement with her symptoms, she presented to our hospital with the same complaints, but more intense than before. On examination, visual acuity in both eyes was 6/9 with spectacles, and intraocular pressure was 14 mmHg in the right eye and 15 mmHg in the left eye. A detailed slit lamp examination was performed, which revealed >5 adult crab-like live lice (on 16x magnification), multiple pinpoint red excretions along with mild hyperaemia, excoriations and brownish scales present on the anterior lid margin and upper lashes in both the eyes [Figure 1]a and [Figure 1]b.
Figure 1: (a) Multiple crust-like deposits over the anterior lid margin and upper lashes with multiple nits and live lice. (b) Multiple pinpoint red excretions with scales and nits adherent to upper lashes

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A number of small, translucent oval eggs (nits) were observed adhering to the lashes and lids of the patient, and moving lice were hanging from the eyelashes [Figure 2].
Figure 2: Live adult lice adherent to the lash

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Some eyelashes, lice and nits were removed mechanically using epilation forceps after applying a topical anaesthetic agent. Force is required to remove the louse the ensure that the head is extracted from the follicle, at which time red dots are observed to appear on the lid margin. There was mild conjunctival congestion, a transparent cornea, an immature senile cataract with no obvious abnormalities in the fundus of both eyes. The patient stated that she had no previous infestations and no history of sexually transmitted diseases. Her serology report for HIV antibodies was negative. She was treated with an oral dose of ivermectin 12 mg once a week for 2 weeks along with topical ciprofloxacin eye ointment 3 times a day for 2 weeks. At the 1-week follow-up examination, the patient's symptoms had subsided completely, but on slit-lamp examination there was the presence of residual nits on few upper eyelashes for which epilation and removal of the nits was done. After 2 weeks, there was a healthy lid margin, and the patient was symptomatically relieved with no new symptoms [Figure 3].
Figure 3: Healthy lid margin on follow-up after epilation

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  Discussion Top

P. pubis is an ectoparasite commonly found infesting the pubic, and axillary region, and less commonly encountered over the eyelids. Most patients in whom the ectoparasitosis has been found have been from a lower socioeconomic status.[7] Considering that hygiene and sharing of clothes, bedsheets and towels play a role in the spread of the ectoparasitosis, is imperative that the family members of the affected by evaluated for infestation.[13] In the current case, all relatives were inquired about symptoms including pruritus, erythema and general discomfort on, or near the eyelids, pubic and axillary region, with none having any positive history of active similar complaints to the presenting patient. Review of the literature shows that only a few cases of phthiriasis palpebrarum have been reported, with a majority of these cases being reported in younger children [Table 1]. All cases reported have ultimately resolved with the management including manual removal of the visible lice and nits from the hair follicles. Other treatment modalities that have been tried and proven successful are mentioned in [Table 1]. Seeing that pubic infestation is the more common site of ectoparasitosis, it is relevant to consider the possibility of sexual abuse in children that present with phthiriasis as they are less likely to be exposed to such conditions leading toward infestation, although transmission through parental or sibling head lice is more common.[14] The current case reports similar results with manual removal of the ectoparasite and topical ciprofloxacin (0.3%) eye ointment application along with 2 doses of Oral Ivermectin 12 mg, leading to healthy lid margins and a symptomatically relieved adult patient.
Table 1: Review of Literature

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  Conclusion Top

A simple case of pruritus should not be overlooked, and a detailed slit-lamp examination is required to rule out P. pubis infestation of the eyelid to prevent misdiagnosis.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Lacarrubba F, Micali G. The not-so-naked eye: Phthiriasis pulpebrarum. Am J Med 2018;126:960-1.  Back to cited text no. 1
Rundle PA, Hughes DS. Phthirus pubis infestation of the eyelids. Br J Ophthalmol 1993;77:815-6.  Back to cited text no. 2
Khan T. Phthiriasis palpebrarum presenting as anterior blepharitis. Indian J Public Health 2018;62:239-41.  Back to cited text no. 3
[PUBMED]  [Full text]  
Sahu S, Bhutia TW, Shrestha V, Kamble VK. Unilateral phthiriasis palpebrarum infestation: An unusual case of pruritis. J Clin Ophthalmol Res 2020;8:70-2.  Back to cited text no. 4
  [Full text]  
Yi JW, Li L, Luo da W. Phthiriasis palpebrarum misdiagnosed as allergic blepharoconjunctivitis in a 6-year-old girl. Niger J Clin Pract 2014;17:537-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
Panos GD, Petropoulos IK, Dardabounis D, Gatzioufas Z. Phthiriasis palpebrarum. BMJ Case Rep 2013;2013:bcr2013009272.  Back to cited text no. 6
Reddy SC. Phthiriasis palpebrarum. Indian J Ophthalmol 1980;28:39-41.  Back to cited text no. 7
[PUBMED]  [Full text]  
Turow VD. Phthiriasis palpebrarum: An unusual course of blepharitis. Arch Pediatr Adolesc Med 1995;149:704-5.  Back to cited text no. 8
Anane S, Malek I, Kamoun R, Chtourou O. Phthiriasis palpebrarum: Diagnosis and treatment. J Fr Ophtalmol 2013;36:815-9.  Back to cited text no. 9
Wu N, Zhang H, Sun FY. Phthiriasis palpebrarum: A case of eyelash infestation with Pthirus pubis. Exp Ther Med 2017;13:2000-2.  Back to cited text no. 10
Kim U, Mishra C, Dheera MS. Phthiriasis palpebrarum in A psychiatric patient. Indian Dermatol Online J 2020;11:125.  Back to cited text no. 11
[PUBMED]  [Full text]  
Thappa DM, Karthikeyan K, Jeevankumar B. Phthiriasis palpebrarum. Postgrad Med J 2003;79:102.  Back to cited text no. 12
Gurnani B, Badri T, Hafsi W. Phthiriasis palpebrarum. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459226/. [Last updated on 2021 Oct 09].  Back to cited text no. 13
Ryan MF. Phthiriasis palpebrarum infection: A concern for child abuse. J Emerg Med 2014;46:e159-62.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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