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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 29-31

Anterior staphyloma in a 6-month-old, severely malnourished child following measles: A case report


Department of Paediatrics, ABU/ABUTH, Zaria, Nigeria

Date of Web Publication20-Jun-2018

Correspondence Address:
Dr. Sani M Mado
Department of Paediatrics, ABU/ABUTH, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssajm.ssajm_23_17

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  Abstract 


Xerophthalmia is an important cause of preventable blindness in Nigerian children. Vitamin A deficiency is not the only cause of staphyloma. The vitamin A deficiency can lead to degenerative changes with subsequent softening of the cornea and protrusion of the uveal tissues through the weakest points. We highlight an under-reported case of right anterior staphyloma in a marasmic, 6-month-old child with probable vitamin A deficiency following measles infection. The child developed a measles-like rash and protrusion of the right eye, associated copious purulent discharge, reddening, and sticking of the eyelids against a background recurrent fever, diarrhea, and progressive weight loss. There was preceding poor nutritional history and the parents are of low socioeconomic background. There was a loss of vision in the right eye and perception of the hand movement in the left eye. He had saline irrigation of the eye, systemic and topical antibiotics, vitamin A in addition to the nutritional rehabilitation, fluid, and electrolytes management. The patient improved significantly and was discharged and followed up at the gastroenterology and ophthalmology clinics. Nutritional rehabilitation using high protein and calories diet, which was cereal-based, was continued at an outpatient basis in addition to growth monitoring. Evisceration of the right eye was planned and the child was yet to have the surgery at the time of writing this report.

Keywords: Malnutrition, measles, staphyloma, vitamin A deficiency


How to cite this article:
Mado SM, Idris HW, Abdullahi SM, Musa S. Anterior staphyloma in a 6-month-old, severely malnourished child following measles: A case report. Sub-Saharan Afr J Med 2018;5:29-31

How to cite this URL:
Mado SM, Idris HW, Abdullahi SM, Musa S. Anterior staphyloma in a 6-month-old, severely malnourished child following measles: A case report. Sub-Saharan Afr J Med [serial online] 2018 [cited 2024 Mar 29];5:29-31. Available from: https://www.ssajm.org/text.asp?2018/5/1/29/234755




  Introduction Top


Vitamin A is an essential micronutrient that is necessary for the maintenance of the integrity of epithelial cells and normal vision among its other functions.[1] Vitamin A deficiency eye disease is an important cause of blindness and affects up to 250 million children globally.[2] It is more common in the resource-limited settings, where it disproportionately affects the under-five children from the very poor socioeconomic background.[2] Vitamin A deficient diet, measles, diarrhea, and other micronutrient deficiencies combine to accentuate the development of blindness from the early stages of xerophthalmia.[3] In Nigeria, the national prevalence of vitamin A deficiency disorders was reported as 28.1%, while that of xerophthalmia was 1.1%.[4] Keratomalacia could either progress to phthisis bulbi or more rarely to staphyloma.[5]


  Case report Top


A 6-month-old boy was referred from a general hospital with fever, diarrhea, and weight loss of four weeks duration, skin rash, and protrusion of the right eye of three weeks duration. The fever was low grade and continuous, with no associated convulsions. Diarrhea was nonbloody, initially having six to eight bouts per day but subsequently decreased to two to four bouts per day following intervention. There was no passage of food particles in the stool and this was the first episode in the child’s life. The child became progressively weak and lost achieved gross motor milestones. Weight loss was associated with anorexia. He was predominantly breastfed until two weeks prior to presentation when he was introduced to complementary liquid feeds mainly made from millet cereals, which were poorly tolerated. The skin rash appeared from the face and was reddish, raised, and nondischarging and progressed caudally to involve the rest of the body within 3 days. The rash subsequently disappeared with desquamation in the same manner it appeared about 5 days from onset. There were preceding catarrhal symptoms and contact with a child with measles-like illness. There was associated copious purulent eye discharge, reddening, and sticking of the eyelids bilaterally with onset of the rash. This progressed to opacity over the right cornea, which began to protrude out into a ball-like mass preventing complete shutting of the right eye. Pregnancy was unsupervised and adversely uneventful. He had no neonatal problems and he received only oral polio vaccine during one of the National Immunization Days. He is the fifth of mother’s five children in a monogamous family setting with both parents having no formal education. The mother is a food vendor, while the father a subsistence farmer. On examination, he was found to be febrile with an axillary temperature of 37.9°C and had a moderate dehydration. He was wasted, anicteric with hypopigmented skin changes, brownish, and sparsely distributed hairs. He had no pedal edema. He weighed 4.3 kg (−5.3 Z-score), weight-for-length was −5.0 Z-score, and height was 62 cm (−3.3 Z-score). The visual acuity was difficult to assess in the right eye, but follows light in the left eye. There were crusted discharges on both the upper and lower eyelids of the right eye. There was total corneal opacity with clear central thinning and protrusion of uveal tissue. He had generalized conjunctival hyperemia and corneal xerosis of the left eye. He was conscious with global hypotonia and hyporeflexia. He had moderate volume pulse and tachycardia. Other systemic examination findings were essentially normal. He was diagnosed as a case of postmeasles debility: marasmus with right anterior staphyloma probably secondary to vitamin A deficiency. Screening for both tuberculosis and retroviral disease was negative. His complete blood count was suggestive of a sepsis and the blood culture yielded Staphylococcus aureus. He had saline irrigation of the eye, systemic and topical antibiotics, vitamin A, and other micronutrients supplementation in addition to the fluid and electrolytes management. He became afebrile by the 3rd day and diarrhea stopped a day later. The eye discharges and reddening as well as other acute symptoms subsided within 2 weeks of admission. The child weighed 5.8 kg at the point of discharge. In addition, at the point of discharge, there was still loss of vision in the right eye while the vision was normal in the left eye. [Figure 1] and [Figure 2] depicted the child at the point of admission and discharge. The eyes were also evaluated by an ophthalmologist from the onset and at the point of discharge. An informed counseling was offered to the parent, and the child was planned to have evisceration of the right eye and to be followed up at pediatric ophthalmology clinic for further management.
Figure 1: Picture of the right and left eyes at the point of admission

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Figure 2: Picture of the right and left eyes at the point of discharge from the ward

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  Discussion Top


Staphyloma affecting the anterior segment of the eye resulting in an abnormal protrusion of the uveal tissue via a weak point in the eye ball can result from inflammatory or degenerative changes affecting the epithelial cells of the cornea. The presumed vitamin A deficiency in the index case can lead to the spectrum of abnormalities ranging from corneal dryness and punctate epithelial erosion to corneal perforations.[5] Staphyloma is not an uncommon cause of blindness, because it was an indication for eye removal in reports from some centers in Nigeria.[6],[7],[8],[9] In one of the reports,[7] staphyloma was the indication for the surgical removal of the eyes in 13.3% of the indications for the removal of the eyes. The presence of severe malnutrition coupled with persistence diarrhea might have contributed to the rapid progression of the disease presenting as staphyloma following attack of measles infection in the index case. A similar case was reported in a child managed for severe malnutrition from India; however, the child presented 2 years later and had evisceration in addition to vitamin A treatment.[5] In Nigeria, the occurrence of severe manifestation of xerophthalmia such as this one underscores the fact that vitamin A deficiency related eye diseases are still very much prevalent despite decades of vitamin A fortification of common food items. This is further compounded by the persistence of measles endemicity, and the current economic challenges that make it difficult for children and pregnant women to access vitamin A rich diet.


  Conclusion Top


Improved immunization coverage against measles, good nutrition, vitamin A supplementation to children, and health education will reduce the prevalence of vitamin A related eye diseases including staphyloma.

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.

Acknowledgements

We would like to thank all the staff of pediatric department of ABUTH Zaria, especially Drs. Ezeokwu, Elwan, and Aminu AT, and staff from other departments who were involved directly or indirectly in the management of this patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sommer A, West KP. Vitamin A Deficiency: Health, Survival, and Vision. New York: Oxford University Press 1996.  Back to cited text no. 1
    
2.
World Health Organization. Nutrition; 2017. Available from: http://www.who.int/nutrition/topics/vad/en/. [Last assessed on 2017 Jul 12].  Back to cited text no. 2
    
3.
Sherwin JC, Reacher MH, Dean WH, Ngondi J. Epidemiology of vitamin A deficiency and xerophthalmia in at-risk populations. Trans R Soc Trop Med Hyg 2012;106:205-14. doi:10.1016/j.trstmh.2012.01.004  Back to cited text no. 3
[PUBMED]    
4.
Ajaiyeoba AI. Vitamin A deficiency in Nigerian children. Afr J Biomed Res 2001;4:107-10.  Back to cited text no. 4
    
5.
Kamei GL, Meitei YC. Anterior staphyloma following serophthalmia − A case report. J Dent Med Sci 2014;13:80-2.  Back to cited text no. 5
    
6.
Ayotunde IA, Michaeline AI, Adenike OA, Tunji SO. Pattern of eye diseases and visual impairment among students in Southwestern Nigeria. Int Ophthalmol 2007;27:287-92.  Back to cited text no. 6
    
7.
Okoye O, Chuka-Okosa CM, Magulike NO. Ten-year rural experience of surgical eye removal in a primary care center south-eastern Nigeria. Rural Remote Health 2013;13:2303.  Back to cited text no. 7
[PUBMED]    
8.
Majekodunmi S. Causes of enucleation of the eye at Lagos University Teaching Hospital. A study of 101 eyes. West Afr J Med 1989;8:288-91.  Back to cited text no. 8
[PUBMED]    
9.
Ibanga A, Asana U, Nkanga D, Duke R, Etim B, Oworu O. Indications for eye removal in southern Nigeria. Int Ophthalmol 2013;33:355-60.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]


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