Endotheliitis-A Presentation of Acanthamoeba Keratitis

To report endotheliitis as an early, key presenting sign of Acanthamoeba keratitis in patients who are soft contact lens wearers.

We report 4 cases of patients presenting with pain, red eye, and reduction in vision in the context of soft contact lens wear. On examination, the predominant clinical finding was that of endotheliitis, localized fusiform stromal edema with corresponding keratic precipitates, anterior chamber inflammation, and minimal epithelial and anterior stromal signs. The classical signs of Acanthamoeba keratitis were not present.

All 4 cases were clinically diagnosed as Acanthamoeba endotheliitis; corneal scrapes were negative; case 1 was polymerase chain reaction positive, and case 3 underwent confocal microscopy that showed double-walled cysts, suggesting Acanthamoeba. All responded well to anti-Acanthamoeba medication alone with 3 cases achieving complete resolution with minimal anterior stromal scarring by 7 weeks. Case 1 had steroid treatment before being seen at our unit and had a prolonged course of treatment with complete resolution by 4 months.

It is imperative to have a high index of suspicion for Acanthamoeba in patients presenting with pain and endotheliitis in the context of contact lens wear, even in the absence of classical signs.