Queratitis fúngica por Colletotrichum spp. A propósito de un caso

Case reportA 23 years old male with an unremarkable past medical history suffered an injury with a branch of a lemon tree in the right eye two days prior to presentation. The slit-lamp examination showed a central corneal erosion with a white tree-shaped stromal infiltrate and Tyndall +/++ in anterior chamber. Cultivation of corneal scraping was positive for Colletotrichum spp. The patient responded favourably to topical amphotericin.DiscussionColletotrichum spp. is an uncommon cause of keratitis, usually secondary to corneal erosion caused by plant material and should be included in the differential diagnosis of fungal keratitis.     

Keratitis with Elizabethkingia meningoseptica Occurring after Contact Lens Wear: A Case Report

To report keratitis with Elizabethkingia meningoseptica, which occurred in a healthy patient after wearing contact lenses for 6 months. A 24-year-old male patient visited our hospital with ocular pain. This patient had a history of wearing soft contact lenses for 6 months, about 10 hours per day. At initial presentation, slit lamp examination showed corneal stromal infiltrations and small epithelial defect. Microbiological examinations were performed from corneal scrapings, contact lenses, and the contact lens case and solution. The culture results from contact lenses, contact lens case and solution were all positive for Elizabethkingia meningoseptica. Thus, we could confirm that the direct cause of keratitis was contamination of the contact lenses. The patient was treated with 0.3% gatifloxacin. After treatment, the corneal epithelial defect was completely healed, and a slight residual subepithelial corneal opacity was observed. We diagnosed keratitis with Elizabethkingia meningoseptica in a healthy young male wearing soft contact lenses. We conclude that Elizabethkingia meningoseptica should be considered as a rare but potential pathogen for lens-related keratitis in a healthy host.     

Phialemonium obovatum Keratitis after Penetration Injury of the Cornea

Phialemonium keratitis is a very rare case and we encountered a case of keratitis caused by Phialemonium obovatum (P. obovatum) after penetrating injury to the cornea. This is the first case report in the existing literature. A 54-year-old male was referred to us after a penetration injury, and prompt primary closure was performed. Two weeks after surgery, an epithelial defect and stromal melting were observed near the laceration site. P. obovatum was identified, and then identified again on repeated cultures. Subsequently, Natacin was administered every two hours. Amniotic membrane transplantation was performed due to a persistent epithelial defect and impending corneal perforation. Three weeks after amniotic membrane transplantation, the epithelial defect had completely healed, but the cornea had turned opaque. Six months after amniotic membrane transplantation, visual acuity was light perception only, and corneal thinning and diffuse corneal opacification remained opaque. Six months after amniotic membrane transplantation, visual acuity was light perception only, and corneal thinning and diffuse corneal opacification remained.     

Candida parapsilosis corneal graft infection from a single eye center: Histopathologic report of 2 cases

Fungal keratitis accounts for 6–53% of all cases of ulcerative keratitis in variable studies. The majority of cases are due to septate fungi. The abnormal cornea in cases of dry eye syndrome, chronic ulceration, erythema multiform and possibly HIV infection is infected more commonly with Candida, most commonly Candida albicans. Candida parapsilosis affects neonates and intensive care unit (ICU) patients and it has been recently found with increasing frequency. In a previous study on mycotic keratitis in our tertiary eye hospital, filamentous fungi were more commonly isolated than yeasts. We are presenting 2 successive cases of corneal graft infection by Candida parapsilosis referred to us from another eye center to attract the attention of ophthalmologists and health workers to such an infection.     

Corneal nerve alterations in acute Acanthamoeba and fungal keratitis: an in vivo confocal microscopy study

Purpose

To study sub-basal corneal nerve alterations in patients with acute Acanthamoeba keratitis (AK) and fungal keratitis (FK), using laser in vivo confocal microscopy (IVCM).

Methods

A retrospective analysis of IVCM (Heidelberg Retina Tomograph 3/Rostock Cornea Module) images of 10 AK corneas and 4 FK corneas was performed, and the results compared with those of 10 normal and 12 acute herpetic keratitis (HK) corneas. Sub-basal corneal nerves were analyzed with respect to total number of nerves, main nerve trunks, branching pattern and total length of nerves per image, as well as tortuosity. For each variable, results for three frames were averaged and analyzed using analysis of variance.

Results

Total corneal nerve length was significantly (P<0.0001) reduced in patients with AK (193.4±124.5 μm) and FK (268.6±257.4 μm) when compared with normal controls (3811.84±911.4 μm). Total nerve counts in patients with AK (3.9±1.2) and FK (3.6±3.2) were significantly (P<0.0001) decreased in comparison with normal controls (24.7±5.5). The number of main nerve trunks and nerve branching was found to be significantly lower in AK and FK corneas, when compared with controls. There was a statistically significant decrease in the above parameters when compared with HK controls.

Conclusions

The sub-basal corneal nerve plexus is significantly diminished in eyes with AK and FK, as demonstrated by IVCM. These results are more profound than previously reported findings of a diminished nerve plexus in HK.     

Rhodotorula mucilaginosa Keratitis: A rare fungus from Eastern India

Rhodotorula mucilaginosa rarely cause keratitis in immunocompromised individuals. A 30 year old male with history of minor trauma presented with cotton wool like stromal infiltration and hypopyon in left eye. Microbiological examination of corneal scraping showed fungal hyphae and yeast cells in direct smear. Molecular identification of the organism was performed which showed 100% homology with Rhodotorula mucilaginosa. Management of these cases is difficult often necessitating surgical procedures. However further reports are necessary to understand the disease and establish a treatment protocol.     

Acridine Orange Staining for Rapid Diagnosis of Acanthamoeba Keratitis

Acanthamoeba keratitis is uncommon, but one of the most severe infectious diseases of the cornea. Delayed diagnosis or misdiagnosis as bacterial or herpes simplex keratitis leads to extensive corneal inflammation and profound visual loss. Therefore, accurate and rapid diagnosis of Acanthamoeba keratitis is essential for successful treatment and good prognosis. We evaluated the usefulness of acridine orange staining from corneal scrapings and contact lens solutions for the rapid diagnosis of four consecutive cases of Acanthamoeba keratitis. Gram stain and culture on nonnutrient agar plates with Escherichia coli overlay were also made. Corneal scrapings stained with acridine orange revealed yellow-to-orange polygonal, cystic structures consistent with the appearance of Acanthamoeba among inflammatory cells and the corneal epithelial cells. The contact lens case solutions of two patients also showed numerous cysts with double wall. Some organisms from the third patient were identified as Acanthamoeba castellani and others as Acanthamoeba lugdunensis. Based on the acridine orange staining results in four cases of Acanthamoeba keratitis, this stain is recommended as a simple and reliable method for the rapid diagnosis of this disease.     

A case of acute postoperative keratitis after deep anterior lamellar keratoplasty by multidrug resistant Klebsiella

A healthy lady of 42 years underwent deep anterior lamellar keratoplasty for granular dystrophy. The very next day, it was complicated by development of infectious keratitis. The organism was identified as multidrug resistant Klebsiella pneumoniae. Donor corneal button may be implicated in the transmission of infection in an otherwise uneventful surgery and follow-up. Nosocomial infections are usually severe, rapidly progressive and difficult to treat. Finally, the lady had to undergo therapeutic penetrating keratoplasty for complete resolution of infection.     

Keratitis with Kocuria palustris and Rothia mucilaginosa in Vitamin A Deficiency

Purpose

To present a case of unusual corneal infection early in the course of peripheral ulcerative keratitis in a patient with severe vitamin A deficiency.

Method

Single observational case report in urban USA.

Case Presentation

An alcoholic patient with pancreatitis, chronic diarrhea, and vitamin A deficiency presented with a marginal corneal ulcer from which two bacteria of the family Micrococcaceae were cultured and identified by genome sequence analysis, namely Kocuria palustris and Rothia mucilaginosa. Soon after, severe bilateral peripheral ulcerative keratitis developed, later accompanied by eyelid cellulitis of one lid. These conditions improved with antibiotics, treatment of the underlying gastrointestinal conditions, and treatment of the vitamin deficiency.

Conclusion

Susceptibility to keratitis with unusual bacteria of the Micrococcaceae family can occur in the setting of alcoholism-related gastrointestinal disease with severe vitamin A deficiency. To our knowledge, K. palustris is a species not previously identified in any human disease, and the Kocuria genus has not previously been reported as a participant in eye infection. Documented cases of R. mucilaginosa in ocular disease are rare. These unusual infections heralded the onset of severe marginal corneal melts.Key words: Kocuria palustris, Rothia mucilaginosa, Peripheral ulcerative keratitis, Vitamin A deficiency     

Clinical characteristics,predisposing factors,and treatment outcome of Curvularia keratitis

Purpose:To report clinical characteristics, predisposing factors, and treatment outcome of Curvularia keratitis.Methods:Retrospective chart review of consecutive culture-proven Curvularia keratitis patients who presented to a tertiary eye care center in north India. Patients with mixed infections with Curvularia as one of the pathogens were also included. Standard case report form was developed to capture demographic information, clinical features, etiology, treatment, and outcome. Binary logistic regression was done to ascertain the effect of identified variables on final visual acuity.Results:Medical records of 97 patients of Curvularia keratitis were reviewed. Median age of patients was 45.3 years. Seventy-nine (79.4%) patients presented during the months of September to November. History of corneal trauma was present in 69.1%. Trauma from sugarcane leaf was identified in 66.1% of cases with corneal trauma with vegetative matter. Presenting visual acuity was worse than 20/60 in 57.8% of patients. Hypopyon and pigmented plaque-like infiltrate was present in 16.5% and 28.8% of patients, respectively. Mixed infection was reported in 14.4% of cases. Median time of antifungal therapy was 24.5 days. Surgical intervention was required in 18.5% cases. Of all, 11.1% patients achieved final VA of more than 20/200 who were managed surgically as compared to 68 (86%) patients who were managed medically. Younger age, absence of comorbidities, and lesser infiltrate size were found associated with good final visual acuity.Conclusion:Working males were most affected by Curvularia keratitis. Corneal trauma with sugarcane leave was the most common predisposing factor in the study area. Most of the cases presented with worse visual acuity but could be managed medically.     

Eradicating blinding trachoma: What is working?

Trachoma remains the leading cause of preventable corneal blindness in developing countries. The disease is contracted in early childhood by repeated infection of the ocular surface by C. trachomatis. Initial clinical manifestation is a follicular conjunctivitis which if not treated on timely basis, may lead to conjunctival and eyelid scarring that may eventually result in corneal scarring and loss of vision. Over the past two decades, a remarkable reduction in the prevalence of active trachoma has occurred due to the World Health Organization’s (WHOs) program GET 2020 for the elimination of trachoma with adoption of the SAFE strategy incorporating Surgery, Antibiotic treatment, Facial cleanliness and Environmental hygiene. However, patients who already had infection at young age may present with adnexal-related complications of trachomatous scarring that may cause corneal scarring and visual loss. These patients may present with evidence of trichiasis/entropion as well as eyelid retraction. Lacrimal complications may include nasolacrimal-duct obstruction, dacryocystitis and canaliculitis requiring intervention. In addition to the increased risk for corneal scarring, trichiasis/entropion may further increase the risks for microbial keratitis in patients who may have unrecognized dacryocystitis and canaliculitis. Female patients may have more trachomtous-related complications and may present at an early age. Available evidence indicates that SAFE strategy may be effective and on the right track towards achieving GET 2020 goal for the eradication of trachoma.     

Queratitis bacteriana por Moraxella nonliquefaciens

Moraxella keratitis can lead to important complications. Moraxella nonliquefaciens (M. nonliquefaciens) has the worst prognosis. Only three cases of corneal infections due to M. nonliquefaciens have been published. The case is presented of a 79-year-old man with bullous keratopathy, recently affected with severe infectious keratitis. Dense, deep, and central stromal infiltrates and hyphaema were detected. After the identification of M. nonliquefaciens in the culture, and given the progression of the condition, the initial empirical treatment was modified to topical ciprofloxacin and ceftazidime in accordance with the antibiogram, combining oral ciprofloxacin and amoxicillin-clavulanate. After 27 days, there was total resolution of the lesion, with central residual leucoma.Keratitis caused by M. nonliquefaciens is rare and must be suspected in elderly patients with local predisposing factors, such as corneal damage or previous eye surgery. Early antibiogram-guided treatment and close monitoring are important to avoid complications and poor compliance.     

Corneal Phaeohyphomycosis Caused by Bipolaris hawaiiensis

PurposeTo report a rare case of keratitis infected by Bipolaris hawaiiensis.MethodsA patient who was diagnosed as fungal keratitis caused by B. hawaiiensis was retrospectively reviewed for history, clinical characteristics, risk factors, laboratory findings, treatments, and outcomes.ResultsA 63-year-old man with a history of trauma and saw dust in the left eye presented with a corneal ulcer. Eye examination revealed whitish infiltration with a feathery edge and small brownish deposits in the anterior stroma of the left cornea. Numerous septate hyphal fragments were detected in a corneal specimen, and nucleotide sequence analysis identified B. hawaiiensis. Treatment was started with 5% natamycin eyedrops and oral itraconazole. Subsequently, a corneal plaque developed which did not respond to medication and debridement. The patient underwent therapeutic penetrating keratoplasty.ConclusionsB. hawaiiensis is a rare cause of corneal phaeohyphomycosis. A brownish pigmented infiltration is an important diagnostic clue, however microbiologic studies are required to obtain a definite diagnosis. Although antifungal medication and debridement are the mainstay of most corneal fungal infection, therapeutic penetrating keratoplasty can prevent morbidity related to this fungal infection.Key Words: Bipolaris hawaiiensis, Phaeohyphomycosis, Keratitis, Dematiaceous fungus     

Molecular characterization of drug-resistant and drug-sensitive Aspergillus isolates causing infectious keratitis

Purpose:

To study the susceptibilities of Aspergillus species against amphotericin B in infectious keratitis and to find out if drug resistance had any association with the molecular characteristics of the fungi.

Materials and Methods:

One hundred and sixty Aspergillus isolates from the corneal scrapings of patients with keratitis were tested for susceptibilities to amphotericin B by broth microdilution method. These included Aspergillus flavus (64 isolates), A. fumigatus (43) and A. niger (53). Fungal DNA was extracted by glass bead vertexing technique. Polymerase chain reaction (PCR) assay was standardized and used to amplify the 28S rRNA gene. Single-stranded conformational polymorphism (SSCP) of the PCR product was performed by the standard protocol.

Results:

Of the 160 isolates, 84 (52.5%) showed low minimum inhibitory concentration (MIC) values (≤ 1.56 μg/ml) and were designated as amphotercin B-sensitive. Similarly, 76 (47.5%) had high MICs (≥ 3.12 μg/ml) and were categorized as amphotericin B-resistant. MIC₅₀ and MIC₉₀ values ranged between 3.12-6.25 μg/ml and 3.12-12.5 μg/ml respectively. A. flavus and A. niger showed higher MIC₅₀ and MIC₉₀ values than A. fumigatus. The SSCP pattern exhibited three extra bands (150 bp, 200 bp and 250 bp each) in addition to the 260 bp amplicon. Strains (lanes 1 and 7) lacking the 150 bp band showed low MIC values (≤ 1.56 μg/ml).

Conclusion:

A. niger and A. flavus isolates had higher MICs compared to A. fumigatus, suggesting a high index of suspicion for amphotericin B resistance. PCR-SSCP was a good molecular tool to characterize Aspergillus phenotypes in fungal keratitis.     

Recurrent corneal erosions causing bacterial keratitis

BackgroundAny etiology of epithelial defect can lead to severe bacterial keratitis. Patients with recurrent corneal erosions suffer repeated corneal epithelial defects without significant trauma and therefore are at risk of infectious keratitis more frequently than someone without recurrent erosions. A stromal infiltrate with an overlying area of epithelial defect can be challenging to differentiate between infectious and noninfectious inflammatory conditions. It is important for clinicians to appreciate the clinical findings in these cases and initiate aggressive treatment promptly.Case ReportA 32-year-old woman presented with a history of anterior basement membrane dystrophy and recurrent corneal erosions. She had symptoms of redness, pain, foreign body sensation, photophobia, epiphora, and burning in her left eye that started 2 days before the visit to our office. Examination showed a large epithelial defect with dense stromal infiltrate inferiorly on the cornea that appeared white and milky with diffuse cellular infiltrate as well as 3+ cells in the anterior chamber.ConclusionLaboratory results were positive for bacterial keratitis (Staphylococcus aureus). Infectious presentation should be considered visually threatening and treated immediately and aggressively. Early intervention is important to help avoid severe complications.     

Fungal keratitis caused by a rare ocular pathogen,Gjaerumia minor: A case report

Fungal keratitis is an important infection of the eye that may cause devastating effects. Keratitis caused by fungi has been described in many parts of the world mainly in tropical countries. The objective of this study is to report a serious eye infection in an adult with a known history of diabetes caused by an uncommon yeast fungus with details of clinical findings and laboratory investigations. Left eye visual acuity was no perception of light due to end stage neovascular glaucoma. The patient was pseudophakic in both eyes. Culture of a corneal scraping showed yeast like organism on Sabouraud dextrose agar. Gjaerumia minor, a rare yeast but with history of a pulmonary infection in the region, was confirmed with 98% similarity in the large subunit ribosomal RNA gene (accession KY690175). Topical Amphotericin B and oral fluconazole were initiated. The patient showed gradual improvement, epithelial defect healed, infiltration steadily regressed and hypopyon disappeared. We report the first case of fungal keratitis caused by G. minor in Saudi Arabia. Fungal Keratitis should be considered in cases where clinical response to the conventional antibacterial antibiotic treatment is not optimal.     

Experience of Comamonas acidovorans keratitis with delayed onset and treatment response in immunocompromised cornea

PURPOSE: To report 2 cases of Comamonas acidovorans keratitis in immunocompromised cornea. METHODS: A complete review of the medical records of the two cases of Comamonas acidovorans keratitis. RESULTS: We found some similarities in clinical courses of two cases. Both of them showed development of keratitis during the management with corticosteroids, delayed onset, slow response to antibiotics, and relatively less affected corneal epithelium. CONCLUSIONS: Comamonas acidovorans is known as a less virulent organism. However it can cause an indolent infection that responds slowly even to adequate antibiotics therapy in immunocompromised corneas.     

Keratitis due to a coelomycetous fungus: case reports and review of the literature

PURPOSE: To describe a series of 7 patients with ulcerative keratitis caused by species of Colletotrichum, which are coelomycetous fungal pathogens. METHODS: The patients presented with keratitis of varying degrees of severity. Multiple scrapes from the corneal lesions of 6 of the 7 patients were used for microbiological investigations by a standard protocol. In the seventh patient, scraping was not performed due to the presence of deep infiltration and a descemetocele at presentation. All 7 patients were hospitalized and treatment was initiated with topical applications of natamycin (5%) and ciprofloxacin (0.3%) every hour and cyclopentolate (1%) drops 3 times daily. An emergency therapeutic penetrating keratoplasty was performed after 48 hours in the patient who had presented with a descemetocele and for another patient whose keratitis did not respond to 10 days of medical therapy. RESULTS: The corneal samples of all 7 patients yielded significant growth of filamentous fungi in culture. On the basis of macroscopic and microscopic characteristics, the fungal isolates were identified as Colletotrichum spp. Corneal lesions completely resolved with medical therapy alone in 5 patients. In the 2 patients who had undergone therapeutic penetrating keratoplasty, the infection was eradicated and the corneal graft remained clear even after several months of follow-up. CONCLUSION: Colletotrichum spp may be more frequent causes of keratitis than previously thought. Keratitis due to Colletotrichum spp frequently responds to medical therapy alone, although surgery may be indicated in a small proportion of patients.     

Microsporidia and Acanthamoeba: the role of emerging corneal pathogens

Parasitic organisms are increasingly recognized as human corneal pathogens. A notable increase in both well-defined Acanthamoeba keratitis and a more dramatic increase in reported cases of Microsporidia keratitis have suggested significant outbreaks of parasitic keratitis around the world. Historical and contemporary baselines as well as a familiar associated clinical presentation reinforce the significant outbreak of Acanthamoeba keratitis in the United States. The remarkable rise in cases of Microsporidia keratitis, however, lacks these established baselines and, further, describes a disease that is inconsistent with previous definitions of disease. While a well-defined, abrupt increase strongly suggests temporally related risk factors, most likely environmental, involved in the Acanthamoeba outbreak, the rise in Microsporidia keratitis suggests that increased awareness and improved diagnostic acumen are a significant factor in case ascertainment. Regardless, recent evidence indicates that both parasitic diseases are likely underreported in various forms of infectious keratitis, which may have unrecognized but significant implications in the pathogenesis of both primary protozoal and polymicrobial keratitis. Further understanding of the incidence and interaction of these organisms with current therapeutic regimens and more commonly recognized pathogens should significantly improve diagnosis and alter clinical outcomes.