Contact lens-related bilateral and simultaneous Acremonium keratitis / Ceratite bilateral e simultânea por Acremonium relacionada ao uso de lentes de contato

Abstract This is a case of bilateral and simultaneous Acremonium keratitis related to intermittent and alternating eye soft contact lens use, which has a delayed diagnose, presented amphotericin B resistance with persistent hypopyon and had a positive response to topical natamycin. Besides the unusual presentation, there was no history of trauma or contact with vegetable matter, usually associated to the majority of cases of keratomicosys by filamentous fungi.

Resumo Trata-se de um caso de ceratite bilateral e simultânea por Acremonium relacionada ao uso intermitente e sem respeitar a lateralidade do uso de lentes de contato gelatinosas. Houve diagnóstico tardio, apresentando resistência a anfotericina B e hipópio persistente, com resposta positiva a natamicina tópica. Além da forma incomum de apresentação, não houve histórico de trauma ou contato com material vegetal, associado à maioria dos casos de ceratite por fungos filamentosos.

Sucessfull management of bilateral presumed Candida endogenous endophtalmitis following pancreatitis / Tratamento bem sucedido de caso de endoftalmite endógena bilateral presumida por Candida pós pancreatite

ABSTRACT Endogenous endophthalmitis is a rare, and frequently devastating, ophthalmic disease. It occurs mostly in immunocompromised patients, or those with diabetes mellitus, cancer or intravenous drugs users. Candida infection is the most common cause of endogenous endophthalmitis. Ocular candidiasis develops within days to weeks of fungemia. The association of treatment for pancreatitis with endophthalmitis is unusual. Treatment with broad-spectrum antibiotics and total parenteral nutrition may explain endogenous endophthalmitis. We report the case of a patient with pancreatitis treated with broad-spectrum antibiotics and total parenteral nutrition who developed bilateral presumed Candida endogenous endophthalmitis that was successfully treated with vitrectomy and intravitreal amphotericin B.

RESUMO Endoftalmite endógena é uma condição oftalmológica rara e frequentemente devastadora. Ocorre principalmente em pacientes imunocomprometidos, diabéticos, com neoplasias ou usuários de drogas intravenosas. Infecção por Candida é a causa mais comum de endoftalmite endógena. A candidíase ocular ocorre de dias a semanas após a fungemia. A associação de endoftalmite e o tratamento para pancreatite é rara. O tratamento com antibióticos de amplo espectro e alimentação parenteral total podem explicar uma endoftalmite endógena. Neste estudo, reportamos o caso de um paciente com pancreatite tratado com antibióticos de amplo espectro e alimentação parenteral total que desenvolveu endoftalmite endógena bilateral presumida por Candida que foi tratado com sucesso com vitrectomia e injeção intravítrea de amfotericina B.

Ocular mycosis at a referral center in Saudi Arabia: a 20-year study

To review the clinical experience of fungal keratitis cases at King Khaled Eye Specialist Hospital [KKESH] in Riyadh, Saudi Arabia. Retrospective observational review and analysis of 124 patient charts with confirmed diagnosis of fungal keratitis between 1984 and 2004. One hundred and twenty four eyes of 124 patients had proven fungal infection; 101 eyes had fungal keratitis and 23 eyes had fungal endophthalmitis complicating keratitis. Estimated proportion of fungal keratitis and endophthalmitis was 10.3%. Mean age was 55 years with male predominance [79.0%]. Commonly associated factors were previous intraocular surgery [38.7%] and trauma [20.9%]. Major risk factor for progressing to endophthalmitis was previous intraocular surgery [65.2%], p < 0.001. Initial laboratory results were fungal positive only in 30.6% [p < 0.001]. Commonest organisms isolated were Aspergillus spp. [29.8%] followed by Trichophyton sp. [16.1%], then Candida and Fusarium sp. Comparison of both phases of the study showed improvement in the rate of successfully treated cases from 34.6% to 58.3%, and a decline in cases progressing to endophthalmitis from 25.0% to 13.9%. Therapeutic penetrating keratoplasty increased from 26.9% to 73.6% [p < 0.001]. Thirteen eyes required enucleation or evisceration. In contrast to other studies on fungal keratitis, Aspergillus spp. and Trichophyton sp. were the most commonly isolated fungal pathogens; the former carries the worst prognosis. Risk factors included previous intraocular surgery and trauma. Poor outcome was associated with Aspergillus spp., delayed presentation, previous intraocular surgery and late surgical intervention. This study recommends early surgical intervention to improve the outcome

Voriconazole-refractory fungal infection of phacoemulsification tunnel.

A 44-year-old man presented 28 days after cataract surgery (phacoemulsification) in right eye with multiple pinpoint infiltrates in posterior stroma at cataract surgery wound site. Visual acuity was 20/60. Corneal scraping from the floor of the corneal tunnel revealed fungus which was later identified to be Aspergillus flavus. The patient was started on oral voriconazole 200 mg twice daily and topical voriconazole 1% every hour. Two intracameral injections of voriconazole (50 micrograms/ 0.1 ml) were given 72 h apart, five days after starting initial therapy. Infiltrates increased in size and density in spite of 20 days of voriconazole therapy. Full-thickness patch graft was done to arrest progressive necrosis. Four months after surgery, patient had 20/60 best-corrected visual acuity. There was no recurrence in one-year follow-up. Present case illustrates the therapeutic challenge in fungal tunnel infections and possibility of voriconazole-resistant Aspergillus species.

Analysis of the risk factors predisposing to fungal, bacterial & Acanthamoeba keratitis in south India.

Background & objectives: Infective keratitis is rare in the absence of predisposing factors. The pattern of risk factors predisposing to infective keratitis varies with geographical regions and also influences the type of infection that occurs. The present study was aimed to identify the specific risk factors that predispose the infective keratitis (non viral) and to determine the association between the risk factors identified and the microbial aetiology of infective keratitis in a geographic region (south India). Methods: A retrospective analysis of all patients clinically diagnosed infective keratitis (non viral) presenting between September 1999 and September 2002 was performed to identify risk factors. After diagnosing infective keratitis clinically, corneal scrapes were performed and subjected to microscopy and culture. Results: A total of 3295 patients with infective keratitis were evaluated, of whom, 1138 (34.5%) patients had fungal growth alone, 1066 (32.4%) had bacterial growth alone, 33 (1%) had Acanthamoeba growth alone, 83 (2.5%) had mixed microbial growth and the remaining 975 (29.6%) had no growth. Corneal injury was identified in 2356 (71.5%) patients and it accounted for 91.9 per cent in fungal keratitis (P<0.0001) (OR: 73.5; 95%CI: 61.3-98.5), 28.1 per cent in bacterial keratitis and 100 per cent in Acanthamoeba keratitis (P<0.0001). Injuries due to vegetative matter (61.2%) was identified as significant risk for fungal keratitis (P<0.0001) (OR: 15.73; 95%CI: 12.7-19.49) and mud (84.85%) for Acanthamoeba keratitis (P<0.0001) (OR: 16.52; 95%CI: 6.35-42.99). Co-existing ocular diseases predisposing to bacterial keratitis accounted for 724 (69%) patients (P<0.0001) (OR: 33.31; 95%CI: 26.98-41.12). Bacterial pathogens alone were recovered from all 35 patients with contact lens associated keratitis (100%). Co-existing ocular diseases (78.3%) were frequently documented among patients older than 50 yr (P<0.0001) (OR: 27.0; 95%CI: 25.0-28.0) and corneal injury (89.7%) was frequently recorded among patients younger than 51 yr (P<0.0001) (OR: 72.0; 95%CI: 70.0-73.0). Interpretation & conclusions: Corneal injury was found to be the principal risk factor for fungal and Acanthamoeba keratitis, while co-existing ocular diseases for bacterial keratitis. Corneal injury with vegetative matter was more often associated with fungal keratitis and injury with mud with Acanthamoeba keratitis.

Bilateral Pseudomonas keratitis without predisposing factors.

Bilateral keratitis usually occurs in predisposed individuals such as contact lens wearers, those suffering from malnutrition and immunodeficiency or patients undergoing bilateral refractive corneal surgery. We report a 30-year-old man without any obvious predisposing factors who presented with complaints of pain and decreased vision in both eyes. Examination revealed corneal ulcers in both eyes, which on microbiological culture grew Pseudomonas aeruginosa. The patient underwent a therapeutic keratoplasty in the right eye while the left eye was managed medically. Bilateral Pseudomonas keratitis can develop in the absence of any obvious predisposing factors.

A study of keratomycosis: our experience.

The aim of the present study was to determine the etiological agents, predisposing factors and important diagnostic tests in keratomycosis in Patna. During period of 2 years, 204 clinically suspected cases of keratomycosis were studied by microscopy (10% KOH smear preparation and Gram's staining) and culture (for bacteria as well as fungus). Out of 204 clinically suspected cases, 76 cases (37.23%) were reported positive for fungus by microscopy and culture. 77% cases were between the age group of 21 to 50 years. Males were more than double the number of females affected. 82% patients were farmers by occupation. 81.58% cases gave a definite history of antecedent corneal trauma. 6.58% cases were known diabetics. Peak incidence was recorded in the months of September-October of the years. Single fungal isolates were present in 63 cases (31%) and multiple were there in 3 cases (1.47%). Mixed isolates of bacteria and fungi were there in 4.90% cases. The predominant isolate was Aspergillus species--42 cases (52.26%) followed by Candida--7 cases (9.21%), Penicillium--6 cases (7.89%) and Fusarium-6 cases (7.89%). Ten (13.15%) of fungal isolates remained unidentified. Therefore mycotic keratitis should be suspected in every patient with a corneal lesion and should be ruled out promptly to save sight and before commencing steroids and antibiotics.

Queratomicosis después de queratotomía radiada / Fungal keratitis after radial keratotomy

La cirugía refractiva es una técnica difundida universalmente, esta técnica es bastante segura, sin embargo, en ocasiones podemos tener complicaciones, y estas pueden ser desde sencillas en su manejo, hasta tener un desenlace fatal. Nosotros reportamos cinco pacientes que desarrollaron micosis corneal, en alguno de los cortes de la cirugía refractiva (queratotomía radiada). Se les aisló, se tipificó y se practicaron estudios histopatológicos en los 5 pacientes. En todos se comprobó la presencia de hongo Fusarium solani. Como es sabido, la infección por este hongo es una de las queratitis micóticas más agresivas. Se manejaron con antimicóticos, transplante y un caso terminó en ptisis bulbi después de manejar su endoftalmitis. Este artículo motiva al cirujano oftalmólogo a extremar precauciones aun en técnicas tan sencillas como la refractiva

Endoftalmitis por acremonium kiliense / Fungal endophthalmitis for acremonium kiliense

Se presenta un caso de endoftalmitis micótica del ojo derecho en un paciente de 26 años, que había sufrido una úlcera traumática la cual se perforó a pesar del tratamiento local y general con antimicóticos. Se debieron realizar sucesivos colgajos conjuntivales para lograr curación, también se utilizó como último recurso una lente de contacto terapéutica. Del material obtenido por raspado de la úlcera de córnea y del humor vítreo se aisló Acremonium kiliense. El tratamiento médico-quirúrgico fue prolongado debido a la agresividad del hongo; se logró salvar la integridad del globo ocular

Hongos oportunistas aislados de lesiones oculares / Fungal keratitis: ethiology and treatment

Los hongos oportunistas son agentes causales de infecciones de córnea en individuos sanos que, frecuentemente, realizan tareas al aire libre y están expuestos a sufrir traumatismos por algún tipo de vegetal. También afectan ojos con alteraciones físicas predisponentes. Se estudiaron 65 pacientes con lesiones de córnea durante el período comprendido entre enero de 1989 y julio de 1992. Las técnicas de laboratorio que se realizaron consistieron en el examen directo de las muestras clínicas y los cultivos. Del total de materiales sólo 9 (13,85%) mostraron la presencia de hongos. El mayor porcentaje de aislamiento correspondió a Fusarium solani (7.69%) seguido por Aspergilus fumigatus (3.08%), Acremonium s.p. (1.54%), Cladosporium s.p. (1.54%). Los pacientes fueron tratados con miconazol, ketoconazol y un caso con natamicina que es la droga de elección para las infecciones oculares debidas a hongos. Merece destacarse la importancia de la búsqueda de estos hongos en infecciones oculares así como la rapidez en el diagnóstico del agente microbiano. De esta manera no sólo se acelera la cura de la afección sino que se reducen los riesgos de complicación y pérdida de la visión

Microbiological studies in conjunctivitis.

A total of 102 cases of clinically diagnosed cases of acute conjunctivitis were included in the present study. The sample was collected from the inflamed conjunctiva and was subjected to conventional bacterial and fungal cultural studies. The allergic element was found out by studying the smear after Giemsa staining and demonstrating increased number of eosinophils. The data revealed that 32 samples had an evidence of bacterial infection, 14 showed isolation of fungi and one displayed an allergic etiology. Thirty cases showed presence of mixed infection in different combinations while 25 samples were sterile on conventional culture media. Microbiological studies are essential for confirmation of clinical diagnosis and to institute an appropriate treatment.