Purpureocillium(P) lilacinum is a ubiquitous, saprophytic filamentous fungus that is infrequently reported in keratitis and cutaneous infections. However, the microbiological characterization of the culture isolates is limited in Korea. A 56-year-old male who suffered a pine needlestick to his right eye 10 days previously presented with ocular opacity and pain. A microscopic examination of a corneal scraping by Gram staining and calcofluor white staining was negative for bacteria and fungi. Fungal culture yielded pure white cottony molds on Sabouraud's dextrose agar after a 3-day incubation. Microscopic examination further revealed a mixture of a verticillate arrangement of phialides resembling the Penicillium structure and sparsely branched conidiophores bearing single to small clusters of conidia. This was initially presumed to be a species of Penicillium but the colonies never turned green with further incubation. It was subsequently identified as P. lilacinum by 28S rDNA sequencing and MALDI-TOF mass spectrometry. Antifungal susceptibility test revealed that this organism was resistant to flucytosine, amphotericin B, fluconazole, itraconazole, voriconazole, and caspofungin. After treatment with topical 5% voriconazole and oral itrazonazole combined with multiple debridements for 2 weeks, the patient was discharged with improved visual acuity. We thus report the first case of P. lilacinum infection that required molecular identification due to mixed conidiogenesis features and that showed laboratory-confirmed antifungal resistance in Korea.
Agar ; Amphotericin B ; Bacteria ; Debridement ; DNA, Ribosomal ; Drug Resistance ; Fluconazole ; Flucytosine ; Fungi ; Glucose ; Humans ; Itraconazole ; Keratitis* ; Korea ; Male ; Mass Spectrometry ; Middle Aged ; Needlestick Injuries ; Penicillium ; Sequence Analysis, DNA ; Spores, Fungal ; Visual Acuity ; Voriconazole

No abstract available.
Aged ; Conjunctiva/*surgery ; Dacryocystorhinostomy/*adverse effects ; Eye Infections, Fungal/diagnosis/*etiology/microbiology ; Female ; Humans ; Keratitis/diagnosis/*etiology/microbiology ; Lacrimal Duct Obstruction/*diagnosis ; Paecilomyces/*isolation & purification ; Recurrence ; Surgical Wound Infection/diagnosis/*etiology/microbiology

Adult ; Antifungal Agents ; therapeutic use ; Eye Infections, Fungal ; diagnosis ; drug therapy ; Humans ; Keratitis ; diagnosis ; drug therapy ; Male

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.
Cornea/*injuries/microbiology/pathology ; Diagnosis, Differential ; Eye Infections, Fungal/diagnosis/etiology/*microbiology ; Eye Injuries, Penetrating/*complications/diagnosis ; Follow-Up Studies ; Fungi/isolation & purification ; Humans ; Keratitis/diagnosis/etiology/*microbiology ; Male ; Middle Aged

BACKGROUNDHypopyon is common in eyes with fungal keratitis. The evaluation of the clinical features, culture results and the risk factors for hypopyon and of the possible correlation between hypopyon and the treatment outcome could be helpful for making treatment decisions.

METHODSThe medical records of 1066 inpatients (1069 eyes) with fungal keratitis seen at the Shandong Eye Institute from January 2000 to December 2009 were reviewed retrospectively for demographic features, risk factors, clinical characteristics, laboratory findings and treatment outcomes. The incidence of hypopyon, the fungal culture positivity for hypopyon, risk factors for hypopyon and the effect of hypopyon on the treatment and prognosis were determined.

RESULTSWe identified 1069 eyes with fungal keratitis. Of the 850 fungal culture-positive eyes, the Fusarium species was the most frequent (73.6%), followed by Alternaria (10.0%) and Aspergillus (9.0%). Upon admission, 562 (52.6%) eyes with hypopyon were identified. The hypopyon of 66 eyes was evaluated via fungal culturing, and 31 eyes (47.0%) were positive. A total of 194 eyes had ocular hypertension, and 172 (88.7%) of these eyes had hypopyon (P < 0.001). Risk factors for incident hypopyon included long duration of symptoms (P < 0.001), large lesion size (P < 0.001) and infection caused by the Fusarium and Aspergillus species (P < 0.001). The positivity of fungal culture for hypopyon was associated with duration of symptoms and lesion size. Surgical intervention was more common in cases with hypopyon (P < 0.001). Hypopyon was a risk factor for the recurrence of fungal keratitis after corneal transplantation (P = 0.002).

CONCLUSIONSHypopyon is common in patients with severe fungal keratitis and can cause ocular hypertension. About half of the hypopyon cases were positive based on fungal culture. Long duration of symptoms, large lesion size and infection with the Fusarium and Aspergillus species were risk factors for hypopyon. The presence of hypopyon increases the likelihood of surgical intervention.

Adult ; Anterior Chamber ; pathology ; Aspergillus ; pathogenicity ; Eye Infections, Fungal ; microbiology ; surgery ; Female ; Fusarium ; pathogenicity ; Humans ; Keratitis ; microbiology ; surgery ; Male ; Microscopy, Confocal ; Middle Aged ; Retrospective Studies ; Risk Factors ; Treatment Outcome

We describe two patients with fungal keratitis refractory to standard antifungal therapy whose conditions were managed with voriconazole. The first case is a patient with endophthalmitis and corneal ulcer due to Candida parapsilosis after receiving a corneal transplant. The patient was treated with amphotericin but showed no signs of improvement. Topical voriconazole, oral voriconazole, and intravitreal voriconazole yielded signs of improvement. The second case is a 63-year-old male who underwent a month of empiric treatment with 0.2% topical amphotericin for fungal keratitis but showed no signs of improvement. Treatment was then provided with 1% voriconazole. Both cases showed effective treatment with voriconazole. Voriconazole may be considered as a new method to treat fungal keratitis refractory to standard antifungal therapy.
Administration, Oral ; Antifungal Agents/*administration & dosage ; Candidiasis/diagnosis/*drug therapy/microbiology ; Cornea/microbiology/pathology ; Diagnosis, Differential ; Dose-Response Relationship, Drug ; Eye Infections, Fungal/diagnosis/*drug therapy/microbiology ; Follow-Up Studies ; Humans ; Keratitis/diagnosis/*drug therapy/microbiology ; Male ; Middle Aged ; Ophthalmic Solutions ; Pyrimidines/*administration & dosage ; Triazoles/*administration & dosage

A 54-yr-old male, who was treated by chemotherapy for gastric cancer 15 months ago, presented to Yongdong Severance Hospital, Seoul, with complaints of pain in his right eye caused by a foreign body from the ground in the previous week. He had been treated with topical and oral antibacterial in addition to antifungal agents, but did not show significant clinical improvement. After a positive corneal culture with mold, topical amphotericin B was added to the initial regimen. The mold was identified as Scedosporium apiospermum by macroscopic and microscopic morphologies and the nucleotide sequences of a fungal PCR product showing 99% homology with those of S. apiospermum (EF151349). He recovered with good results at 25 days after corneal epithelial debridement. The early diagnosis of S. apiospermum keratitis is very important for proper treatment. It is recommended that molecular diagnostic methods such as fungal PCR and sequencing be done with conventional cultures whenever a fungal infection is suspected.
Amphotericin B/therapeutic use ; Anti-Bacterial Agents/therapeutic use ; Antifungal Agents/therapeutic use ; Cornea/microbiology ; Drug Therapy, Combination ; Eye Infections, Fungal/*diagnosis/microbiology ; Humans ; Keratitis/*diagnosis/microbiology ; Male ; Middle Aged ; Polymerase Chain Reaction ; Scedosporium/genetics/growth & development/*isolation & purification ; Sequence Analysis, DNA

PURPOSE: To describe the successful treatment of a series of fungal ocular infections with voriconazole. METHODS: A retrospective chart review was conducted for six eyes of five patients: four eyes of four patients with fungal keratitis, and two eyes of one patient with fungal endophthalmitis who were treated with topical and intracameral voriconazole. A battery of analyses on corneal isolates, clinical outcomes, duration of treatment, time to remission, complications, concomitant medication, and visual acuity at the initial and last visits was performed. RESULTS: Six eyes of five patients were treated in total. Three eyes with fungal keratitis were treated with 5% topical voriconazole, and infection was controlled. Therapeutic penetrating keratoplasty was performed on one eye with fungal keratitis due to impending corneal perforation; this eye was treated successfully with topical voriconazole without recurrent inflammation. Both eyes of one patient with fungal endophthalmitis were given an intracameral voriconazole (100 microgram/0.1 cc) injection twice in the right eye and once in the left eye, and infection was controlled with continued topical voriconazole therapy. There was no clinically remarkable corneal epithelial toxicity from topical application. No corneal endothelial toxicity was observed after an intracameral injection of voriconazole. CONCLUSIONS: Voriconazole is known to penetrate efficiently into ocular tissues. As shown in our case series, voriconazole is a new, promising therapy for intractable fungal ocular infection.
Endophthalmitis ; Eye ; Eye Infections, Fungal ; Humans ; Inflammation ; Keratitis ; Keratoplasty, Penetrating ; Pyrimidines ; Retrospective Studies ; Time-to-Treatment ; Triazoles ; Visual Acuity

Background: Fungal keratitis is a serious ocular infection that can cause corneal scarring and blindness. Currently, diagnosis of fungal pathogens remains a difficult problem. Objectives: To investigate the application of semi-nested PCR targeted ITS genes for detection of fungal agents causing keratitis. Material and method: Ten identified fungal strains, 4 bacterial strains, 20 scraping samples from patients with suspected fungal keratitis and 2 scraping samples from patients with suspected bacterial keratitis were tested using semi-nested PCR. Results: Semi-nested PCR showed positive results for the samples of identified fungal strains and for the 20 scraping samples from patients with suspected fungal keratitis. Neither samples of bacterial strains nor scraping samples from suspected bacterial keratitis patients gave positive PCR results. Conclusion: Semi-nested PCR is a robust tool for specific and rapid detection of fungal agents causing keratitis.
Fungal keratitis ; semi-nested PCR

Colletotrichum is mainly a fungal pathogen of plants, but sporadic cases of human infection have been reported recently. Most of them are fungal keratitis and only a few cases have been reported worldwide. A 63-year-old female farmer developed foreign body sensation and watering in her left eye following trauma by rice leaves. At presentation, her visual acuity decreased and corneal ulcer and inflammation in anterior chamber were observed on a slit lamp examination. Numerous hyphae were found on Gram stain and a rapidly growing mold with cup-shaped acervuli and falcate and nonseptate conidia was observed on fungal culture. As morphological findings did not lead to definite differentiation of the organism, sequencing of the D1-D2 domain of 28S rDNA was performed. It proved to be Colletotrichum species and the patient was treated with amphotericin and natamycin eye drop, but complicated by acute glaucoma. This is the first report of Colletotrichum keratitis in Korea and suggests that its infection should be considered in patients with fungal keratitis.
Amphotericin B ; Anterior Chamber ; Colletotrichum* ; Corneal Ulcer ; DNA, Ribosomal ; Female ; Foreign Bodies ; Fungi ; Glaucoma ; Humans ; Hyphae ; Inflammation ; Keratitis* ; Korea ; Middle Aged ; Natamycin ; Sensation ; Spores, Fungal ; Visual Acuity ; Water