Japanese spotted fever (JSF) is caused by Rickettsia japonica, and lethal cases are reported yearly in southwest Japan. We thus established the method of diagnosing JSF by immunohistochemistry (IHC) and real-time PCR (RT-PCR) using formalin-fixed, paraffin-embedded skin biopsy specimens. Two monoclonal antibodies were used for IHC, and the 17k genus common antigen gene served as the target of RT-PCR. We collected skin biopsy (n = 61) and autopsy (n = 1) specimens from 50 patients clinically suspected of JSF. Immunohistochemically, the rickettsial antigens were localized as coarse dots in the cytoplasm of endothelial cells and macrophages. Thirty-one seropositive cases plus one autopsy case (group A) and nine seronegative cases but with positive IHC and/or RT-PCR (group B) were judged as JSF. Nine cases were regarded as non-JSF disorders based on negative serology, IHC and RT-PCR (group C). Of 50 biopsies (eschar 34, eruptions 10, and scabs 6) from groups A and B, IHC and RT-PCR positivities were 94% (32/34) and 62% (21/34) for eschar, 80% (8/10) and 30% (3/10) for eruptions, and 33% (2/6) and 50% (3/6) for scabs. For IHC, eschar was most suitable, and scabs were insufficient. Unexpectedly, 18 biopsies happened to be fixed in 100% formalin, and this lowered the detection rate by RT-PCR, but IHC was tolerant. Sequence analysis using five skin biopsy specimens confirmed a 114 bp DNA stretch homologous to that reported for the target gene of R. japonica. In 26 (84%) of the 31 seropositive patients, the diagnosis was made by IHC and/or RT-PCR earlier than serology.

BackgroundHere we report three cases of conjunctival lymphoma that were initially unnotified or misdiagnosed as other ocular diseases because of the small tumor size, peripheral tumor location (the tumor was hidden in the fornix), and nonspecific symptoms.MethodsThree patients diagnosed with conjunctivitis or nasolacrimal duct obstruction were referred to our clinic because they were unresponsive to standard medical treatments. Routine anterior segment examination did not reveal any lesions, but further careful examination with a strong eyelid draw revealed minimally elevated tumors in the peripheral fornix under the lid. Excisional biopsies were performed.ResultsHistopathologic and immunohistologic examinations indicated the presence of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). All patients underwent additional radiation therapy. There was no evidence of recurrence in any patient during the follow-up period.ConclusionDetection of conjunctival lymphoma can be challenging. If no apparent lesion is present and the patient has nonspecific symptoms, the inner surface of the eyelid should be carefully examined. Elaborate eyelid eversion, with eyeball movement, should be performed to avoid misdiagnosing or overlooking peripheral conjunctival lymphomas.

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