Patients with herpes simplex virus, usually present with eyelid vesicles or epithelial dendrites, but these changes are not always present. Acanthamoeba presents as a painful stromal infiltrate most typically in a contact lens user. Noninfectious causes can be sterile, noninfectious ulcers related to dry eye syndrome, collagen vascular diseases such as rheumatoid arthritis or vitamin A deficiency. The lack of coexisting medical problems or previous symptoms would argue against these conditions in this particular case. Phlyctenulosis and staphylococcal antigen hypersensitivity occur as smaller infiltrates in the periphery.
Foreign material inoculated into the cornea can present as infiltrates.
For example, there can be marked stromal inflammation in response to a rust ring. Finally, contact lens related immune reactions develop as painful, subepithelial, sterile infiltrates, but these infiltrates are multifocal and smaller than in the current case. After the negative workup, because of the high suspicion for fungal or parasitic infection and given the subacute presentation, fungal scrapings and a Calcofluor were repeated within a few days of the first scraping. Several small cysts were identified on Calcofluor white immunofluorescence, and a diagnosis of Acanthamoeba keratitis was made. All rights reserved.