Schizophyllum commune: A New Organism in Eye Infection

Purpose

We report a case of mycotic keratitis caused by a rare fungus Schizophyllum commune.

Methods

Clinical examination, slit-lamp examination, and microbiological evaluation of the corneal ulcer were done, and its treatment outcome was studied. The fungal etiology was established by conventional microbiological techniques, polymerase chain reaction and speciation by DNA sequencing.

Results

Corneal scraping showed the presence of fungal filaments. The fungus was identified as S. commune based on DNA sequence analysis of the internal transcribed spacer region. The organism was susceptible to amphotericin B and voriconazole and demonstrated resistance to anidulafungin, itraconazole, and fluconazole. Therapeutic keratoplasty was performed but there was recurrence of the infection in the graft, which was controlled with topical voriconazole and intracameral amphotericin B. At the end of 3 months, the affected eye had developed phthisis bulbi.

Conclusion

The best of our knowledge, this is the first reported case of keratitis caused by the rare fungus S. commune. Management of these cases is difficult, and surgical procedures may be needed.     

Fungal Keratitis Secondary to <Emphasis Type="Italic">Trametes betulina</Emphasis>: A Case Report and Review of Literature

Purpose

We report the first case of human infection and keratitis secondary to Trametes betulina, a rare filamentous fungus.

Methods

Clinical examination including external and slit-lamp examination and corneal scrapings with microbiologic evaluation were performed on a patient with chronic allergic conjunctivitis, entropion and a long-standing corneal ulcer resistant to treatment.

Results

The culture from the corneal scraping revealed a basidiomycetous fungus which was submitted for identification. DNA extraction with sequencing and analysis of the ITS and D1/D2 regions were performed on the isolate and demonstrated 100% similarity to Lenzites betulina/Trametes betulina. Susceptibility testing demonstrated potent in vitro activity of voriconazole (MIC < 0.03 μg/ml). The patient was treated with voriconazole, and the corneal ulcer and infiltrate resolved. The infection resulted in corneal thinning and a dense central corneal scar. Penetrating keratoplasty was performed 5 months after diagnosis and treatment and revealed stromal scarring without fungal elements.

Conclusion

This is the first reported case of keratitis caused by Trametes betulina. This organism should be considered in the differential diagnosis for rare filamentous fungal keratitis and its treatment with voriconazole also noted.

     

Queratitis fúngica por Curvularia hominis: primer caso descrito en España

Background

Dematiaceous fungal genus Curvularia is a causal agent of keratitis, onychomycosis, and skin infections. In 2014, using DNA sequencing techniques, five new species, including Curvularia hominis, were described. In this article, a report is presented on the first clinical case of C. hominis infection in Spain. It concerns a corneal ulcer caused by this recently described species.

Lasiodiplodia theobromae Keratitis: A Case Report and Review of Literature

A case report and review of literature is reported of a rare case of fungal keratitis from eastern India. A 32-year-old woman with a history of vegetative trauma presented with keratitis in left eye. Microbiological examination of corneal scraping showed refractile hyphae with aseptate branching filaments and black pigmented colonies on multiple solid agar medium. Organism was identified from culture using D1/D2 region of LSU (Large Sub Unit: 28S rDNA)-based molecular technique. PCR amplified a band with a sequence that was 100?% homologous with Lasiodiplodia theobromae. The organism was susceptible to amphotericin B and voriconazole and demonstrated resistance to itraconazole and fluconazole. A therapeutic keratoplasty was performed following non-responsiveness to initial topical voriconazole (2?%) therapy. Recurrence in graft was controlled with topical voriconazole and intracameral amphotericin B. However, the graft failed at the end of 3?months. L. theobromae is a rare cause of fungal keratitis. Management of these cases is difficult, often involving surgical procedures.     

Mycotic Keratitis Caused by <Emphasis Type="Italic">Fusarium solani sensu stricto</Emphasis> (FSSC5): A Case Series

Owing to a lack of appropriate diagnostic and therapeutic approaches for mycotic keratitis, approximately one million cases of preventable corneal blindness are reported each year. The number of keratitis cases due to infection with Fusarium is increasing significantly worldwide, many of which are not treated adequately and in a timely manner due to frequent misdiagnosis. In the current report, we describe three cases of keratitis caused by Fusarium solani sensu stricto (FSSC5) from Turkey and The Netherlands, following ocular trauma. The etiological agent of keratitis, FSSC5, identified by sequencing of the partial tef1-α gene, exhibited low minimum inhibitory concentrations (MICs) of 1 µg/mL for amphotericin B and high MICs above the published epidemiological cutoff values for voriconazole (8 µg/mL). Patients were successfully treated with topical amphotericin B and voriconazole with complete recovery.     

<Emphasis Type="Italic">Aspergillus flavus</Emphasis> Keratitis: Experience of a Tertiary Eye Clinic in Turkey

We investigated the clinical and mycological characteristics of four cases of mycotic keratitis caused by Aspergillus flavus that occurred from July 2014 to May 2015 at Çukurova University Hospital, Adana, Turkey. In a 10-month period, a total of 64 corneal smear/scrapings were examined from patients with suspected mycotic keratitis. Fungal cultures were positive in six of these patients, indicating a 9.4% incidence of mycotic keratitis in this region, including four cases of A. flavus and two cases of Fusarium spp. The predisposing factors, clinical presentation, and success of the therapeutic approaches were further evaluated. For all cases, topical voriconazole was the first choice of treatment. Surgical procedures were required to control infection in 3 of the 4 cases, including intrastromal voriconazole injection for two cases and keratoplasty for one case. Predisposing factors included trauma (two cases, 50%), contact lens use (one case, 25%), and previous ocular surgery (one case, 25%). The clinical presentations also differed, including a well-limited ulcer (one case), an ulcer with an irregular feathery margin (one case), and ulcers with satellite lesions (two cases). The mean duration between the time of presentation and definitive diagnosis by culture was 14 days (8–25 days). We observed that A. flavus keratitis can present with different underlying factors and clinical conditions. A combination of antifungal therapy and supportive surgical intervention may resolve infections caused by A. flavus in the cornea.     

两种手术方式治疗真菌性角膜炎的临床观察

目的 观察深板层角膜移植术（deep lamellar keratoplasty,DLKP）和穿透性角膜移植术（penetrating keratoplasty,PKP）治疗真菌性角膜炎的临床疗效.方法 回顾44例（44眼）临床确诊为真菌性角膜炎的患者,根据共焦激光显微镜检查是否累及角膜内皮分别行DLKP 28例（28眼）或PKP 16例（16眼）.术后随访6～24个月,观察术后真菌复发情况以及拆线后两周视力和角膜地形图散光.结果 术后角膜病理切片检查均检出真菌.术后DLKP组有1例、PKP组有3例出现排斥反应,经抗排斥治疗后均好转.拆线后两周最佳矫正视力DLKP组为0.59×0.04,PKP组为0.41 ×0.05,两组间相比较差异具有统计学意义（t =2.577,P =0.01）;角膜地形图散光DLKP组为（2.0 ×0.17） D;PKP组为（2.9×0.30）D,两组间相比较差异具有统计学意义（t =0.088,P=0.016）.结论 激光共焦显微镜检查对于手术方式的选择提供了良好的客观依据.两种手术方式治疗真菌性角膜炎均有良好的疗效,DLKP术后视觉疗效优于PKP.     

Fungal Eye Infections: New Hosts,Novel Emerging Pathogens but No New Treatments?

Purpose of Review

We sought to explore the current incidence and associated risk factors associated with fungal eye infections. We also reviewed new diagnostic strategies and recent clinical studies exploring the use of topical and oral antifungal agents.

Recent Findings

Incidence and associated risks continue to vary with geographic region, and access to timely healthcare. Nosocomial fungal endophthalmitis can result from minor surgical procedures to the eye. Molecular methods offer increasing diagnostic utility. Clinical treatment studies have mainly focussed on the treatment of fungal keratitis and have been conducted in South Asia. Topical natamycin remains superior to topical reconstituted voriconazole and remains the preferred therapy including for Fusarium eye infections. Neither adjunctive oral ketoconazole nor oral voriconazole has been shown to have added clear benefit to topical treatment.

Summary

Larger international studies with more heterogenous populations are required for future clinical studies which should include patients with contact lens fungal keratitis and those with fungal endophthalmitis. Basic science studies exploring the immunology of fungal eye infections and drug levels to understand the differences in clinical outcomes are encouraged.

     

茄病镰刀菌感染致角膜溃疡1例

报告1例由茄病镰刀菌感染引起的角膜溃疡。患者男性,40岁,木工,左眼红、痛、流泪、视力下降10 d。经过角膜清创,系统性及局部抗真菌治疗后好转。致病菌株经真菌学鉴定为茄病镰刀菌,它是真菌性角膜炎的常见致病菌之一。真菌性角膜炎病程进展迅速,能否及早诊治关系预后。真菌学检查是确诊的依据,临床应予重视。     

Corneal transplantation: study of the data of a regional eye bank for the year 2013 and analysis of the evolution of the adverse events reported in France since 2010

To analyze the data of the adverse events collected in a single major eye bank (EFS Bourgogne Franche Comté, Besançon, France) for the year 2013 and to report the French data of biovigilance provided by the French National Agency for Medicines and Health Products Safety (ANSM) between 2010 and 2013. we have set up a study of adverse events in 2013, in collaboration with a single eye bank (EFS Bourgogne Franche Comté, Besançon, France). A survey was sent to the surgeon for each delivered corneal button by the eye bank in 2013. They were asked for each grafted patient performed in their center, the type of graft (penetrating keratoplasty, anterior keratoplasty or endothelial keratoplasty), the occurrence of adverse events (primary failure, infectious keratis, endophthalmitis, immune rejection, and other events) and the time interval between surgery and events (Less than 1 postoperative month, between 1 month and 1 year postoperatively, >1 year postoperatively). In 2013, 407 corneal buttons were delivered by the eye bank of Besançon in 21 medical centers which performed corneal grafts and we sent 407 surveys. We received 243 completed questionnaires (59.75%) from 11 centers (52.38%). The global reported rate of adverse events was 27.54% of the graft (n = 65/236 corneal grafts performed in 11 centers in 2013; 20% of Primary graft failure, 11% of infectious keratitis, 1% of endophthalmitis, 34% of rejection, 34% of other incidents). 30.16% of complications were noticed before the first month after surgery versus 52.38% of complications noticed between the first month and the first year after surgery and 17.46% of complications noticed after the post-operative first year The most common causes of adverse events after PK were Immune rejection (13.17%), surgical causes (5.98%) and infection (4.79%) and after EK were Primary graft failure (8.2%) and surgical causes (19.67%). In 2013, in France 0.83% of adverse events were notified in ANSM. For the 236 performed graft issued from a major eye bank (EFS Besançon) in 2013 the global reported rate of post-graft adverse events was 27.54% of the grafts (20% of Primary graft failure, 11% of infectious keratitis, 1% of endophthalmitis, 34% of rejection and 34% of other incidents). Compared to the ANSM data (0.83% of adverse events reported in 2013) this rate is high. This difference can be explained by the low rate of annual notification to the ANSM and shows that biovigilance in France must be more developed. Since biovigilance needs constant improvement for the safety of the graft system, training, information for practitioners, simplifications of procedures and international standardization of the definition are the main points that could be improved.     

Successful Medical Management of Recalcitrant Fusarium solani Keratitis: Molecular Identification and Susceptibility Patterns

Fungal keratitis is a rare but sight-threatening infection of the cornea that may be caused by several fungal pathogens. A delay in diagnosis and inadequate treatment may even lead to loss of the affected eye. Fungal keratitis is often misdiagnosed as bacterial keratitis because isolation and identification of the fungal pathogen is difficult and requires experience, and fungal growth in culture requires time. In this report, a 14-year-old boy with recalcitrant Fusarium solani keratitis, unresponsive to initial therapy, is presented. CLSI M38-A2 in vitro antifungal susceptibility tests demonstrated that only amphotericin B (0.5 μg/ml) had potent activity against F. solani; however, fluconazole (>64 μg/ml), itraconazole (>16 μg/ml), voriconazole (8 μg/ml), and posaconazole (>16 μg/ml) had high minimum inhibitory concentrations. In addition, caspofungin (>16 μg/ml) and anidulafungin (>16 μg/ml) exhibited high minimum effective concentrations. Repeated intrastromal voriconazole injections, topical voriconazole, and caspofungin combined with systemic antifungal agents improved of the corneal lesion with a significant increase in visual acuity. Intrastromal voriconazole injection may be used as an adjunctive treatment method for recalcitrant fungal keratitis with no prominent complications. The intrastromal route could be an effective route of administration of antifungal agents, especially for F. solani keratitis, as in this case. A combination of various antifungal agents administered by different routes prevented loss of the eye.     

Trichophyton Spp. fungal keratitis in 22 years old female contact lenses wearer

Fungal keratitis represents one of the most difficult forms of microbial keratitis to diagnose and treat successfully. It is difficult to obtain correct diagnosis and topical antifungal preparations. Fungi can cause severe stromal necrosis and enter the anterior chamber by penetrating an intact Descemet membrane. The most common pathogens are filamentous fungi (Aspergillus and Fusarium spp.) and Candida albicans. The incidence of Trichophyton spp. keratitis is 5%. A 22 years old female contact lenses wearer after keratitis developed corneal melting syndrome, spontaneous perforation of the cornea and complicated cataract of the left eye. Conjunctival swab was sterile as well as first sample of corneal tissue and sample from the anterior chamber. Urgent therapeutic perforating keratoplasty (PK), was performed together with extracapsular cataract extraction and the implantation of the intraocular lens in the posterior chamber. The patient was treated with ciprofloxacin and diflucan (systemic therapy); with dexamethason and atropin (subconjunctivaly) and chlorhexidine, brolene, levofloxacin, polimyxin B, and dexamethason/neomycin (topically). Microbiology evaluation was performed once again following excisional biopsy of the intracameral portion of the lesion. The presence of Trichophyton spp. was finally confirmed. Itraconazole and garamycin were included in the systemic therapy. Corneal graft was clear for 17 days but decompensated 28 days after the PK. After two weeks microorganisms invaded the vitreous and caused endophthalmitis. Despite urgent pars plana vitrectomy patient developed endophthalmitis, lost light sensation and developed phthysis. Evisceration and the implantation of silicon prosthesis was done. Perforating keratoplasty is a method of choice in treating severe infectious keratitis unresponsive to conservative treatment but without the eradication of microorganisms it cannot restore the vision or save the eye. Trichophyton spp. may cause a severe disease of the anterior and posterior part of the eye which may finish with the lost of vision/eye. Prompt diagnosis and treatment of Trichophyton spp. keratitis are essential for a good visual outcome.     

Corneal Collagen Cross-Linking for the Management of Mycotic Keratitis

Purpose

To evaluate the efficiency of corneal collagen cross-linking (CXL) in addition to topical voriconazole in cases with mycotic keratitis.

Design

Retrospective case series in a tertiary university hospital.

Participants

CXL was performed on 13 patients with mycotic keratitis who presented poor or no response to topical voriconazole treatment.

Methods

The clinical features, symptoms, treatment results and complications were recorded retrospectively. The corneal infection was graded according to the depth of infection into the stroma (from grade 1 to grade 3). The visual analogue scale was used to calculate the pain score before and 2 days after surgery.

Main Outcome Measures

Grade of the corneal infection.

Results

Mean age of 13 patients (6 female and 7 male) was 42.4 ± 17.7 years (20–74 years). Fungus was demonstrated in culture (eight patients) or cytological examination (five patients). Seven of the 13 patients (54%) were healed with topical voriconazole and CXL adjuvant treatment in 26 ± 10 days (15–40 days). The remaining six patients did not respond to CXL treatment; they initially presented with higher grade ulcers. Pre- and post-operative pain score values were 8 ± 0.8 and 3.5 ± 1, respectively (p < 0.05).

Conclusions

The current study suggests that adjunctive CXL treatment is effective in patients with small and superficial mycotic ulcers. These observations require further research by large randomized clinical trials.

     

Epidemio-Clinico-Microbiological Study of Mycotic Keratitis in North-West Region of Rajasthan

Aim and Objectives

Mycotic keratitis, with its diverse clinical presentation and difficulties in treatment, makes it a challenging task for clinicians and an important object of study. The aim of present study was to determine the frequency of occurrence and epidemiological association with identification of fungal isolates from mycotic keratitis cases.

Materials and Methods

This was a prospective and observational study conducted in Mycology Laboratory, Department of Microbiology, S.P. Medical College, Bikaner, on corneal scrapings and swabs of a total of 480 patients attending the Ophthalmology OPD, P.B.M. Hospital, Bikaner, during July 2005 to June 2012.

Results

Out of 480 suspected cases, 180 were found to be positive for fungus by smear/culture examination. Increased incidence was seen in the months of May to September with Aspergillus fumigatus being the most common isolate.

Conclusion

Mycotic keratitis, though an age-old disease, still presented with challenging aspects of diagnosis and treatment. The study showed fungal keratitis is prevalent in rural parts of north-west Rajasthan, mainly found in males (age group 21–40 years) with low socio-economic status (farm or factory workers). The most common cause of fungal keratitis was found to be species of Aspergillus.

     

Queratomicosis en un centro de atención oftalmológica en la Ciudad de México

BackgroundSome of the most common precipitating events for keratomycoses (fungal keratitis), include surgical trauma (after cornea transplantation), the use of contaminated contact lenses or alterations in lacrimal secretions. Diagnosis and treatment (to avoid loss of vision) for these type of infections are challenging.ObjectiveRetrospective review of the diagnosis, epidemiology, etiology and response to treatment in 219 patients with fungal keratitis in Mexico.MethodsWe have studied the diagnosis, epidemiology, etiology and response to treatment in 219 patients from different states in the Mexican Republic in the Cornea Department at an Ophthalmology Hospital in Mexico D.F.ResultsTrauma was the precipitating event in 77 patients (36%), of which 12 (5.4%) were due to surgical trauma; 152 patients (64.8%) did not report any prior trauma. There were 165 male (75.3%) and 54 female (24.6%) patients, with an average age of 46 years old. For clinical and visual treatment patients were treated with topical and oral antifungals and surgery. One or more surgeries were performed on a total of 81 patients (36.9%). A total of 62 patients (28.3%) received a corneal transplant, and 19 patients (8.7%) were subjected to conjunctival flap or scleral-conjunctival surgery.ConclusionsIn Mexico, keratomycoses affect mostly male patients in a 4:1 ratio over females. Fusarium solani was the most frequent agent of fungal keratitis in our study (37.2%), and the highest number of corneal ulcers and eviscerations (26%) was present in patients infected by Aspergillus. The best therapeutic responses were with combination of topical antifungals against dematiaceous fungi.     

Characterization of Edenia gomezpompae Isolated from a Patient with Keratitis

Edenia gomezpompae, isolated from a patient suffering from keratitis, who was an agricultural worker with a 4-year history of diabetes mellitus, is described. Fungal hyphae were detected in corneal scrapings after microscopic examination and repeated culture. Isolates were identified by morphology and by sequencing the internal transcribed spacer region of ribosomal DNA. Chlamydospore characteristics of E. gomezpompae are described for the first time. The in vitro antifungal susceptibilities of the isolate were tested using five antifungal agents. With the exception of fluconazole, the other drugs (natamycin, amphotericin B, itraconazole, and voriconazole) assayed were highly effective against this fungus. The keratitis was cured after debridement of the corneal ulcer and treatment with 5 % natamycin. After 3 months, when the patient was reexamined, the corneal ulcer showed signs of healing, with no recurrence. To our knowledge, this is the first reported case of keratitis caused by E. gomezpompae, as well as being the first known case of disease in humans caused by this species.     

Evaluation of molecular identification of Aspergillus species causing fungal keratitis

Fungal keratitis caused by the species of Aspergillus is a common and leading problem in developing countries like India. In this study, a total of 135 isolates from Aspergillus keratitis were studied by sequence analyses of the internal transcribed spacer (ITS) region performed by nucleotide-nucleotide BLAST analysis followed by the initial identification of the isolates based on conidial and colony morphology. The sequence analysis revealed several unusual species which were never reported in eye infections such as A. tamrii, A. tubingensis, A. braslliensis, A. nomius, A. pseudonomius, A. sydowii, Eurotium amstelodami. The sequence analysis of the ITS region; the β-tubulin and calmodulin genes brought out the genetic diversity among the isolates as the study intended to locate a more sensitive target sequence to study genetic diversity among a set of test fungal isolates. The PCR amplified sequences of the test isolates of the study as well as sequences belonging to section Flavi obtained from Genbank database were compared and analyzed along with three standard isolates by phylogenetic tree (Neighbor-joining) as to find out a target region/gene that could produce a better resolution to differentiate the isolates. Accordingly, the calmodulin gene had provided better resolution compared to ITS and β-tubulin to study the diversity among the test Aspergillus species isolated from fungal corneal ulcer.     

角膜激光共聚焦显微镜在单眼感染性角膜炎疾病诊断中的应用

摘要 目的：探讨角膜激光共聚焦显微镜在单眼感染性角膜炎疾病诊断中的应用价值。方法：回顾性研究2020年6月到2021年6月选择在本院诊治的单眼感染性角膜炎疾病患者62例,所有患者都给予角膜激光共聚焦显微镜检查,记录影像学特征并判断诊断价值（以病原学诊断为金标准）。结果：真菌性角膜炎在角膜激光共焦显微镜下的病变区纵横交错的高反射的真菌菌丝或高反光细长颗粒状的孢子,细菌性角膜炎的病变处会聚集活化的树突状细胞及大量的炎症细胞,病毒性角膜炎的基底膜下神经纤维密度、神经主干的分支数减少,棘阿米巴性角膜炎的包囊表现为圆形高反光厚壁结构。角膜激光共聚焦显微镜判断为病毒性角膜炎17例,诊断病毒性角膜炎的敏感性与特异性为94.4 %和100.0 %;角膜激光共聚焦显微镜判断为棘阿米巴性角膜炎4例,诊断棘阿米巴性角膜炎的敏感性与特异性为94.4 %和100.0 %;角膜激光共聚焦显微镜判断为细菌性角膜炎21例,诊断细菌性角膜炎的敏感性与特异性为95.5 %和97.5 %;角膜激光共聚焦显微镜判断为真菌性角膜炎20例,诊断真菌性角膜炎的敏感性与特异性为94.4 %和93.2 %。ROC曲线分析显示角膜激光共聚焦显微镜诊断细菌性角膜炎、真菌性角膜炎、病毒性角膜炎、棘阿米巴性角膜炎的曲线下面积分别为0.525、0.579、0.777、0.731。结论：角膜激光共聚焦显微镜在单眼感染性角膜炎疾病诊断中的应用能较好的区分细菌性角膜炎、真菌性角膜炎、病毒性角膜炎、棘阿米巴性角膜炎,具有良好的诊断敏感性与特异性。     

14例茄病镰刀菌所致角膜溃疡临床分析

目的探讨真菌性角膜溃疡的病原学特点、临床表现及抗真菌综合治疗的方法。方法对2004年10月-2006年10月送检的疑似感染的角膜标本进行镜检、培养及菌种鉴定。对其中14例病历资料完整的茄病镰刀菌所致角膜溃疡患者进行临床分析。结果在33例送检标本中分离出茄病镰刀菌24株（72．7％）。上述14例患者中,有3例角膜穿孔合并眼内炎行眼球内容物除去术,3例行结膜瓣或羊膜移植,1例角膜移植,7例经非手术治疗保留较好视力。结论茄病镰刀菌是我国北方真菌性角膜炎的主要致病菌,可导致视力严重受损且治愈困难。早期诊断配合以抗真菌为主的综合治疗可阻止病情进展,明显改善视力。