Fusarium keratitis in Brazil: genotyping, in vitro susceptibilities, and clinical outcomes.

BACKGROUND: The purpose of this paper is to describe clinical characteristics and determine correlations between clinical outcomes and antifungal susceptibility among molecularly characterized ocular Fusarium isolates in Brazil. METHODS: Forty-one Fusarium isolates obtained from 41 eyes of 41 patients were retrieved from the ophthalmic microbiology laboratory at São Paulo Federal University and grown in pure culture. These isolates were genotyped and antifungal susceptibilities determined for each isolate using a broth microdilution method. The corresponding medical records were reviewed to determine clinical outcomes. RESULTS: The 41 isolates were genotypically classified as Fusarium solani species complex (36 isolates, 88%), Fusarium oxysporum species complex (two isolates, 5%), Fusarium dimerum species complex (one isolate, 2%) and two isolates that did not group into any of the species complexes. Final best corrected visual acuity varied from 20/20 to light perception and was on average 20/800 (logarithm of the minimum angle of resolution (LogMAR) 1.6). A history of trauma was the most common risk factor, being present in 21 patients (51%). Therapeutic penetrating keratoplasty was necessary in 22 patients (54%). Amphotericin B had the lowest minimum inhibitory concentration for 90% of isolates (MIC90) value (2 µg/mL) and voriconazole had the highest (16 µg/mL). There was an association between a higher natamycin MIC and need for therapeutic penetrating keratoplasty (Mann-Whitney test, P < 0.005). CONCLUSION: Trauma was the main risk factor, and therapeutic penetrating keratoplasty was necessary in 54% of patients. Amphotericin B had the lowest MIC90 (2 µg/mL) of the three antifungal agents tested. There was an association between higher natamycin MIC levels and corneal perforation, emphasizing the need for antifungal susceptibility testing and tailoring of antifungal strategies.

Fusarium keratitis: genotyping, in vitro susceptibility and clinical outcomes.

PURPOSE: To determine differences in the clinical characteristics and antifungal susceptibility patterns among molecularly characterized ocular Fusarium sp isolates. METHODS: Fifty-eight isolates of Fusarium sp obtained from 52 eyes of 52 patients were retrieved from the Ocular Microbiology Laboratory of the Bascom Palmer Eye Institute and grown in pure culture. These isolates were characterized based on DNA sequence analysis of the ITS1/2 and ribosomal deoxyribonucleic acid regions. Antifungal susceptibilities were determined for each isolate using broth microdilution methods, and the corresponding medical records were reviewed to determine the clinical outcomes. RESULTS: Fusarium solani isolates had significantly higher values of minimum inhibitory concentration for 90% isolates (MIC90) with voriconazole than F. non-solani organisms (16 and 4 µg/mL, respectively). Isolates of F. solani also exhibited a significantly longer time to cure (65 vs. 40.5 days), a worse follow-up best-corrected visual acuity (20/118 vs. 20/36), and an increased need for urgent surgical management (7 vs. 0 penetrating keratoplasties) when compared with those of F. non-solani. CONCLUSIONS: This is the first report to examine the correlation between ocular genotyped Fusarium sp and clinical outcomes. It supports the overall worse prognosis of F. solani versus F. non-solani isolates, including higher voriconazole resistance by the former. The clinical implementation of molecular-based diagnostics and antifungal efficacy testing may yield important prognostic and therapeutic information that could improve the management of fungal ocular infections.

A novel rat contact lens model for Fusarium keratitis.

PURPOSE: The aim of this study was to develop and characterize a new contact lens-associated fungal keratitis rat model and to assess the ability of non-invasive spectral-domain optical coherence tomography (SD-OCT) to detect pathological changes in vivo in fungal keratitis. METHODS: We used SD-OCT to image and measure the cornea of Sprague Dawley rats. Fusarium infection was initiated in the rat eye by fitting Fusarium solani-soaked contact lenses on the experimental eye, while the control animals received contact lenses soaked in sterile saline. The fungal infection was monitored with periodic slit-lamp examination and in vivo SD-OCT imaging of the rat eye, and confirmed by histology, counting of viable fungi in the infected rat cornea, and PCR with specific primers for Fusarium sp. RESULTS: We imaged and measured the rat cornea with SD-OCT. Custom-made contact lenses were developed based on the OCT measurements. Incubation of contact lenses in a F. solani suspension resulted in biofilm formation. We induced contact lens-associated Fusarium keratitis by fitting the rat eyes for 4 h with the Fusarium-contaminated contact lenses. The SD-OCT images of the cornea correlated well with the slit-lamp and histopathological results and clearly defined clinical signs of infection, namely, increased corneal thickening, loss of epithelial continuity, hyper-reflective areas representing infiltrates, and endothelial plaques characteristic of fungal infection. Moreover, in three cases, SD-OCT detected the infection without any clear findings on slit-lamp examination. Infection was confirmed with histological fungal staining, PCR, and microbiological culture positivity. CONCLUSIONS: We developed a highly reproducible rat contact lens model and successfully induced contact lens-associated Fusarium keratitis in this model. The clinical presentation of contact lens-associated Fusarium keratitis in the rat model is similar to the human condition. SD-OCT is a valuable tool that non-invasively revealed characteristic signs of the fungal infection and could provide sensitive, objective monitoring in fungal keratitis.

Clinical and microbiological characteristics of fungal keratitis in the United States, 2001-2007: a multicenter study.

OBJECTIVE: To study the epidemiology, clinical observations, and microbiologic characteristics of fungal keratitis at tertiary eye care centers in the United States. DESIGN: Retrospective multicenter case series. PARTICIPANTS: Fungal keratitis cases presenting to participating tertiary eye care centers. METHODS: Charts were reviewed for all fungal keratitis cases confirmed by culture, histology, or confocal microscopy between January 1, 2001, and December 31, 2007, at 11 tertiary clinical sites in the United States. MAIN OUTCOME MEASURES: Frequency of potential predisposing factors and associations between these factors and fungal species. RESULTS: A total of 733 cases of fungal keratitis were identified. Most cases were confirmed by culture from corneal scraping (n = 693) or biopsies (n = 19); 16 cases were diagnosed by microscopic examination of corneal scraping alone; and 5 cases were diagnosed by confocal microscopy alone. Some 268 of 733 cases (37%) were associated with refractive contact lens wear, 180 of 733 cases (25%) were associated with ocular trauma, and 209 of 733 cases (29%) were associated with ocular surface disease. No predisposing factor was identified in 76 cases (10%). Filamentous fungi were identified in 141 of 180 ocular trauma cases (78%) and in 231 of 268 refractive contact lens-associated cases (86%). Yeast was the causative organism in 111 of 209 cases (53%) associated with ocular surface disease. Yeast accounted for few cases of fungal keratitis associated with refractive contact-lens wear (20 cases), therapeutic contact-lens wear (11 cases), or ocular trauma (21 cases). Surgical intervention was undertaken in 26% of cases and was most frequently performed for fungal keratitis associated with ocular surface disease (44%). Surgical intervention was more likely in cases associated with filamentous fungi (P = 0.03). Among contact lens wearers, delay in diagnosis of 2 or more weeks increased the likelihood of surgery (age-adjusted odds ratio = 2.2; 95% confidence interval, 1.2-4.2). CONCLUSIONS: Trauma, contact lens wear, and ocular surface disease predispose patients to developing fungal keratitis. Filamentous fungi are most frequently the causative organism for fungal keratitis associated with trauma or contact lens wear, whereas yeast is most frequently the causative organism in patients with ocular surface disease. Delay in diagnosis increases the likelihood of surgical intervention for contact lens-associated fungal keratitis.

Trends in fungal keratitis in the United States, 2001 to 2007.

OBJECTIVE: Fungal keratitis is a serious ocular infection that is considered to be rare among contact lens wearers. The recent Fusarium keratitis outbreak raised questions regarding the background rate of Fusarium-related keratitis and other fungal keratitis in this population. DESIGN: Retrospective, multicenter case series. PARTICIPANTS: Six hundred ninety-five cases of fungal keratitis cases who presented to 1 of 10 tertiary medical centers from 2001 to 2007. METHODS: Ten tertiary care centers in the United States performed a retrospective review of culture-positive fungal keratitis cases at their centers between January 2001 and December 2007. Cases were identified using microbiology, pathology, and/or confocal microscopy records. Information was collected on contact lens status, method of diagnosis, and organism(s) identified. The quarterly number of cases by contact lens status was calculated and Poisson regression was used to evaluate presence of trends. The Johns Hopkins Medicine Institutional Review Board (IRB) and the IRBs at each participating center approved the research. MAIN OUTCOME MEASURES: Quarterly number of fungal keratitis cases and fungal species. RESULTS: We identified 695 fungal keratitis cases; 283 involved the use of contact lenses. The quarterly number of Fusarium cases increased among contact lens wearers (CLWs) during the period that ReNu with MoistureLoc (Bausch & Lomb, Rochester, NY) was on the market, but returned to prior levels after withdrawal of the product from the market. The quarterly frequency of other filamentous fungi cases showed a statistically significant increase among CLWs comparing October 2004 through June 2006 with July 2006 through December 2007 with January 2001 through September 2004 (P < 0.0001). CONCLUSIONS: The quarterly number of Fusarium fungal keratitis cases among CLWs returned to pre-Renu with Moistureloc levels after removal of the product from the market. However, the number of other filamentous fungal keratitis cases, although small, seems to have increased among refractive CLWs. Reasons for these apparent increases are unclear.

Drug-resistant severe Acanthamoeba keratitis caused by rare T5 Acanthamoeba genotype.

OBJECTIVE: To describe a case of severe and drug-resistant Acanthamoeba keratitis in a contact lens wearer caused by atypical T5 Acanthamoeba genotype (Acanthamoeba lenticulata). METHODS: Report of a case, Acanthamoeba DNA amplification and sequencing. RESULTS: A 61-year-old patient was referred to our clinic with a 2-week history of keratitis. Acanthamoeba keratitis (AK) was diagnosed using confocal microscopy and corneal scraping culture. Using polymerase chain reaction (PCR) and DNA sequencing, the organism was classified as a T5 genotype (A. lenticulata). The keratitis continued to progress despite topical antiamoebic therapy and ultimately led to enucleation of the affected eye. CONCLUSIONS: T5 genotype Acanthamoeba can cause severe AK. Atypical Acanthamoeba genotypes could be associated with worse prognosis and resistance to therapy.

Utility of molecular sequence analysis of the ITS rRNA region for identification of Fusarium spp. from ocular sources.

PURPOSE: Fungal ocular infections cause significant ocular morbidity, particularly when diagnosis and treatment are delayed. Accurate morphologic identification of Fusarium spp. beyond the genus is time-consuming and insensitive. It was the purpose of this study to examine the usefulness of the nuclear ribosomal RNA (rRNA) internal transcribed spacer regions (ITS1 and -2) to detect and differentiate Fusarium spp. responsible for ocular infections. METHODS: Fifty-eight archived isolates from ocular sources of 52 patients diagnosed with Fusarium keratitis at the Bascom Palmer Eye Institute (Miami, FL) from April 2000 to May 2007 were analyzed. The archived samples, which were initially classified according to morphologic characteristics, were analyzed by DNA sequence data generated from the ITS regions of the rRNA genes. RESULTS: Fifteen distinct sequences were identified among the 58 isolates. Sequence analysis identified the isolates as Fusarium solani (75%), F. oxysporum (16%), F. incarnatum-equiseti (5%), F. dimerum (2%), and one Fusarium sp. (2%) that was not classified within any species complex. Species identification based on sequence data correlated well with the morphologic classification when performed by a mycology reference laboratory, but a higher rate of mismatch was observed based on identification by a nonreference laboratory. CONCLUSIONS: Most of the isolates of Fusarium ocular infections belong to the F. solani or F. oxysporum species complexes. Morphologic classification at the species level yielded inconsistent results at a general microbiology laboratory. In contrast, the sequence variation within the ITS region allowed reliable and faster discrimination of the isolates at both the genus and species level.