Endogenous fungal endopthalmitis treated with intravitreal caspofungin in a COVID-19 recovered patient: A case report

We present a case of endogenous fungal endophthalmitis in a nondiabetic, nonhypertensive patient who recovered from COVID-19 infection. Endogenous fungal endophthalmitis in an immunocompetent individual is quite uncommon. The organism in our patient was resistant to amphotericin and voriconazole and was successfully treated with intravitreal caspofungin. The rarity of an opportunistic nosocomial infection in an immunocompetent person with a drug-resistant organism prompted us to write this report.     

Mycotic keratitis: Susceptibility to antiseptic agents

Oculomycosis is a severe problem in most developing countries. Specific antifungal agents are often unavailable, and are expensive. The use of antiseptic agents was therefore explored. Fungal isolates from patients in India and Ghana were tested against chlorhexidine, povidone iodine, propamidine, and polyhexamethylenebiguanide, and compared with econazole by placing the drugs in wells made in Sabouraud's agar plates seeded with the test organism. Fungal sensitivity testing is a contentious area but this method is simple and cheap. Chlorhexidine showed a good dose related response, povidone iodine showed a good response at all concentrations and econazole was the most effective in vitro. A small pilot study was conducted in India to assess clinical efficacy for fungal corneal ulcers. Both chlorhexidine and econazole proved effective but povidone iodine was ineffective. We suggest that chlorhexidine may be a useful first line agent for fungal keratitis when other antifungals are not available.     

Management of Fusarium keratitis and its associated fungal iris nodule with intracameral voriconazole and amphotericin B

A retrospective case report on the management of a 56‐year‐old man who was diagnosed with Fusarium keratitis with an associated iris fungal nodule. He presented with persistent right ocular pain, redness, photophobia and reduced vision following an injury six weeks earlier. Conservative management with topical antibiotics and intracameral injections was successfully used to treat a rare case of Fusarium keratitis with an associated fungal iris nodule. The patient had complete resolution of his vision. Therefore, conservative management of the fungal nodule is a successful therapy without the risk of anterior chamber dissemination, which may occur with surgical resection.     

Scedosporium prolificans corneoscleritis: A successful outcome

Background: A case of Scedosporium prolificans corneoscleritis is reported in a patient who had developed scleral necrosis following pterygium surgery, with adjunctive β-irradiation. This fungus has been reported to be the causative organism in only two previous cases of corneoscleritis. Methods: The patient presented with signs and symptoms typical of corneoscleritis. When the fungus was isolated from a biopsy specimen, aggressive scleral debridement was carried out and intensive antifungal therapy was instigated. Results: After a prolonged course, the eye was rendered sterile. Conclusion: Early conjunctival recession and aggressive scleral debridement combined with intensive instillation of antifungals are crucial to the successful management of fungal corneoscleritis.     

Traumatic Acremonium atrogriseum keratitis following laser-assisted in situ keratomileusis

A 52-year-old man underwent bilateral laser-assisted in situ keratomileusis. Eight months later, he sustained a penetrating corneal injury to the left eye. A dense white infiltrate, unresponsive to antimicrobial therapy, developed in the corneal stroma. Corneal biopsy and eventual penetrating keratoplasty were performed, and both specimens demonstrated fungal elements with branching, septate hyphae. Culture identified the organism as Acremonium atrogriseum. Histopathologic features of this organism and its differentiation from other, more common fungal organisms are discussed herein.     

Aspergillus flavus keratitis.

Corneal infection due to the species Aspergillus flavus is rare and often destructive. This report describes a case of Aspergillus flavus corneal ulcer that failed to respond to amphotericin B, pimaricin, and clotrimazole. The eye subsequently became phthisical. The rational approach to the management of fungal corneal infection is to culture or perform sensitivity tests on the isolated organism. Early surgical intervention should be done if the infection fails to respond to medical treatment, and if the disease process extends deep into the stromal tissue and anterior chamber. Fungal malignant glaucoma requires excisional keratoplasty, lens extraction, and anterior vitrectomy.     

Fungal keratitis associated with ocular rosacea

In order to report fungal keratitis in patients of ocular rosacea, a retrospective review of all cases of fungal keratitis was undertaken. Cases in which ocular rosacea coexisted were identified and included in the study. The clinical course of patients thus identified was studied from the medical records and outcomes were evaluated. A total of three cases of fungal keratitis with coexisting ocular rosacea were identified. All three patients were known cases of acne rosacea with an intermittent, irregular treatment for the same. Previous history of contact lens use, ocular surgery or trauma was not present in any of the cases. Microbiological evaluation revealed Aspergillus flavus as the causative organism in two patients and an unidentified hyaline fungus in the third. Patients received simultaneous therapy for fungal keratitis and ocular rosacea. The ocular surface completely stabilized and the infiltrate resolved in all three cases. The chronic ocular surface changes and induced inflammation in ocular rosacea, along with the instillation of topical steroids for therapy, may create an environmental milieu favorable for fungal keratitis. Microbiological evaluation should be considered, even in cases of suspected sterile keratitis, prior to treatment with topical steroids, so as to prevent the possible worsening of an associated infective corneal condition.     

Entomophthoramycosis: a rare fungal orbital infection presenting with dacryocystitis

We report a case of a rare fungal orbital infection in an infant presenting with dacryocystitis. The causative organism was Conidiobolus sp. of the order Entomophthorales. There is no standard treatment for entomophthoramycosis. Our patient responded well to combined antifungal therapy without aggressive surgical débridement.     

Culture-Proven Candida Albicans Endogenous Endophthalmitis in a Patient with Onychomycosis

ABSTRACT

Purpose: To report a case of Candida albicans endogenous endophthalmitis in an immunocompetent patient with onychomycosis.

Methods: Retrospective case report.

Results: A 40-year-old man with onychomycosis presented with C. albicans subretinal abscess in the left eye. Systemic and intravitreal injections did not prevent further progression of the infection. The patient underwent pars plana vitrectomy. One month after surgery, the intraocular inflammation gradually subsided. However, his visual acuity stayed at counting fingers as a result of macular scarring.

Conclusion: The aim of this case presentation is to emphasize that endogenous fungal endophthalmitis can be seen in an immunocompetent patient. The use of systemic steroids in the past was the main reason for the progression of the disease in this case. In these situations, when the clinical findings suggest a fungal etiology, it should keep in mind that endogenous candida endophthalmitis can be a result of fungal infections from distant sites such as the toenails and systemic steroids should not be started before definite diagnosis.     

Candida dubliniensis endophthalmitis: first case in North America

To report an unusual case of endogenous fungal endophthalmitis due to Candida dubliniensis. Interventional case report of a 27-year-old immunocompetent male with loss of vision, dense vitritis, and chorioretinal infiltrates, who underwent a diagnostic pars plana vitrectomy. Microbiology cultures obtained by a diagnostic vitrectomy were positive for the growth of C. dubliniensis. This infectious process was then appropriately treated with intravitreal amphotericin B and systemic fluconazole with resolution of the endophthalmitis. Endogenous fungal endophthalmitis is a condition that can masquerade other more common causes of endophthalmitis. Atypical cases of endophthalmitis may benefit from diagnostic pars plana vitrectomy for prompt diagnosis and treatment.     

Clinical and microbial spectrum of fungal keratitis in Singapore: a 5-year retrospective study

Background: The epidemiology of fungal keratitis varies geographically, but commonly occurs in warm, tropical climates. To determine the microbial and clinical characteristics of this disease in Singapore, we conducted a5-year hospital-based retrospective study. Methods: A retrospective reviewo f culture-positive fungal keratitis at the Singapore National Eye Center and Singapore General Hospital, from January 1991 to December 1995. Results: Twenty-nine consecutive cases of culture-positive fungal keratitis were seen over the study period. The mean age of the cases was 41 years and 23 were males. Amongst the varied occupations, 9 were construction workers. The most common cultured organisms were Fusarium sp. (52%) and Aspergillus flavus (17%). More than half had a history of ocular trauma prior to the development of keratitis, while a quarter had antecedent topical corticosteroid therapy. In contrast, only 2 patients were contact-lens wearers. Despite medical therapy, 10 patients eventually required therapeutic penetrating keratoplasties; of these, 6 were caused by Fusarium species. Conclusion: Fusarium is the commonest cultured organism in fungal keratitis in Singapore and is associated with significant ocular morbidity. This revised version was published online in August 2006 with corrections to the Cover Date.     

Post-traumatic fungal endophthalmitis caused by Exophiala jeanselmei

Fungal endophthalmitis caused by dematiacious fungi is an uncommon occurrence. We report a case of fungal endophthalmitis caused by Exophiala jeanselmei following penetrating injury. This is a previously unreported etiologic agent in endophthalmitis. The infection was treated with intravitreal and intravenous amphotericin B in combination with oral 5-fluorocytosine. Although the organism was eradicated, vision was lost due to total retinal detachment.     

<Emphasis Type="Italic">Aspergillus keratitis</Emphasis> in vernal shield ulcer—a case report and review

An unusual case of vernal shield ulcer with superadded fungal keratitis caused by Aspergillus fumigates is reported. A 26-year-old man, a known case of vernal keratoconjunctivitis (VKC) presented with the complaint of diminution of vision in the right eye. Patient was on topical steroids and anti-allergic treatment for the past two months. In the right eye, a shield ulcer with an elevated plaque was seen. Scrapings from the right cornea revealed fungal filaments on a wet KOH mount and culture revealed growth of Aspergillus fumigatus. The patient was diagnosed as VKC with shield ulcer with secondary fungal keratitis. The patient was treated with topical cyclosporine, topical moxifloxacin, topical natamycin, and topical amphotericin eye drops. The patient responded well and finally recovered to a best spectacle-corrected visual acuity of 20/20 at the end of nine months. The chronic ocular surface changes and induced inflammation in VKC, and the instillation of topical steroids for therapy, may create an environmental milieu favorable for fungal keratitis. Microbiological evaluation should be considered, even in cases of suspected sterile keratitis, to prevent possible worsening of an associated infective corneal condition. This warrants patient education, periodic reviews and a very cautious approach to indiscriminate use of topical corticosteroids in cases of VKC with shield ulcer. In the event of any secondary fungal infection, use of steroid sparing topical agent, for example cyclosporine may be considered.     

Femtosecond Laser-Assisted Intra-Corneal Drug Delivery

Abstract

Purpose: To present a case of fungal keratitis that was successfully treated with direct intrastromal medication delivery through a corneal incision created with the femtosecond laser. Methods: A 71-year-old female patient with recurrent episodes of an unresponsive, deep stromal keratitis for six months’ duration, resistant to various therapeutic approaches, was referred to our institute. The 150?kHz Intralase iFS laser (Abbott Medical Optics Inc., Santa Ana, CA) was used to create a corneal pocket in an attempt to permit drug delivery directly into the corneal abscess. Results: Five days after the intrastromal injections, the clinical condition was improved. Two years after the procedure, the cornea is stable and free of any clinical signs or symptoms of recurrence. Conclusions: In this case report, an alternative application of femtosecond laser technology is presented, performing intrastromal drug delivery through a corneal incision for the treatment of fungal keratitis.     

Endogenous Nocardia asteroides subretinal abscess diagnosed by transvitreal fine-needle aspiration biopsy

The authors report a case of an endogenous Nocardia asteroides subretinal abscess in an immunosuppressed cardiac transplant recipient. On clinical grounds, the metastatic subretinal abscess was initially thought to be a fungal, atypical bacterial, or viral lesion. Transvitreal fine-needle aspiration biopsy of the lesion yielded a sufficient specimen for immediate preliminary identification of the microorganism and permitted prompt initiation of an appropriate antibiotic regimen. The definitive diagnosis was based on culture of the organism from the needle aspirate.     

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.     

<Emphasis Type="Italic">Nocardia</Emphasis> Keratitis in a Human Immunodeficiency Virus Patient

Background The development of Nocardia keratitis in a patient with human immunodeficiency virus infection is rare, and we could find no cases reported in the literature.Case A 48-year-old woman who had human immunodeficiency virus infection presented with decreased visual acuity, redness, and irritation in the right eye.Observations Initially, the diagnosis was fungal keratitis, and she was treated with 0.3% amphotericin B eye drops and oral fluconazole for 1 month without improvement. Then, all former drugs were discontinued, and a corneal scraping was carried out. The culture result disclosed Nocardia asteroides, and after treatment with 10% sulfacetamide eye drops and oral trimethoprim-sulfamethoxazole, the keratitis subsided dramatically.Conclusions The treatment result for Nocardia keratitis in a human immunodeficiency virus patient was favorable after intensive use of 10% sulfacetamide eyedrops. Nocardia keratitis should be kept in mind as a possible causative organism when antifungal therapy fails in a keratitis case. Jpn J Ophthalmol 2004;48:272–275 © Japanese Ophthalmological Society 2004     

Bipolaris hawaiiensis-caused phaeohyphomycotic orbitopathy. A devastating fungal sinusitis in an apparently immunocompetent host

The authors present a case report of a devastating bilateral optic neuropathy and orbitopathy initiated by a contiguous fungal sinusitis, in an apparently immunocompetent young man. The causative organism, Bipolaris hawaiiensis, and other species classified in the genus Bipolaris, are being recognized with increased frequency as causes of several ophthalmic and systemic disorders in both immunocompromised and normal hosts. A literature review demonstrates the variety of clinical presentations with emphasis on those cases which may present to the ophthalmologist.     

An Unusual Case of Fungal Chorioretinitis in an Immunocompetent Individual

Purpose: To describe a case of fungal chorioretinitis in a healthy individual. Design: Case report. Results: A 74-year-old immunocompetent man presented with peripheral chorioretinitis with hemorrhage in the superonasal quadrant. A retinal biopsy was performed. PAS and Gomori methenamine silver stain disclosed fungal structures identified as broad nonseptate hyphae with right-angle branches, probably belonging to the Zygomycete class. A systemic workup was initiated to seek the source of the infection with normal findings. The patient was successfully treated with intravitreous and intravenous amphotericine B. Conclusion: Nontraumatic fungal chorioretinitis can present in immunocompetent patients.