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Two Cases of Keratomycosis Caused by Fusarium Solani: Therapeutic Management Fili S*, Schilde T, Perdikakis G and Kohlhaas M

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Two Cases of Keratomycosis Caused by Fusarium Solani: Therapeutic Management Fili S*, Schilde T, Perdikakis G and Kohlhaas M Case Report iMedPub Journals Journal of Eye & Cataract Surgery 2016 http://www.imedpub.com/ Vol.2 No.1:9 ISSN 2471-8300 DOI: 10.21767/2471-8300.100009 Two Cases of Keratomycosis Caused by Fusarium Solani: Therapeutic Management Fili S*, Schilde T, Perdikakis G and Kohlhaas M Department of Ophthalmology, St.-Johannes-Hospital, Johannesstrasse, Dortmund, Germany *Corresponding author: Fili S, Department of Ophthalmology, St.-Johannes-Hospital, Johannesstrasse, Dortmund, Germany, Tel: 004915206428718; E-mail: [email protected] Received date: December 25, 2015; Accepted date: March 10, 2016; Published date: March 14, 2016 Citation: Fili S, Schilde T, Perdikakis G, Kohlhaas M (2015) Welcome Letter. J Eye Cataract Surg 2:9. doi: 10.21767/2471-8300.100009 Copyright: © 2016 Fili S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abbreviations Abstract EUCAST: European Committee on Antimicrobial susceptibility Testing, MIC: Minimum inhibitory concentration Backgrounds: To report 2 cases of multidrug-resistant fungal keratitis caused by Fusarium solani. The patients underwent a different conservative and surgical therapy Introduction including in both of them a keratoplasty à chaud. Keratomycosis is the greek word equivalent to fungal keratitis, Methods and Findings: A 21-years-old male and a 26-years- and it refers to a corneal infection caused by fungi which can old female patient, who both used soft contact lenses end up in severe loss of visual acuity or even enucleation. Fungal developed corneal infiltrates. In the first case the diagnosis keratitis is encountered in tropical climates and in populations was delayed because multiple microbiological examinations related to land cultivation. In the United States keratomycosis is of corneal scrapings were initially negative for fungi. A significantly more common to the southern states. Outbreaks of combined empirical therapy against Acanthamoeba and fungal ceratitis have been attributed in the past to specific bacteria resulted in no improvement of the clinical findings. contact lens solutions. In Germany there are no specific The patient underwent a keratoplasty à chaud and the histopathologic analysis of the corneal button yielded epidemiologic data on keratomycosis. We investigated two Fusarium solani multiresistant to all antifungal agents. In different cases of multidrug-resistant fungal keratitis caused by the second case, Fusarium solani was detected in the initial Fusarium solani that did not respond to the intensive microbiological examination of the corneal scrapings. conservative local and systemic antifungal therapy—ultimately Although the fungus was multiresistant to all antifungal requiring a keratoplasty à chaud; one of the cases progressed to agents, an aggressive multiple topical antifungal therapy as endophthalmitis, and finally required an enucleation. well as lyposomal Amphotericin B i.v was applied successfully after the keratoplasty à chaud combined with application of Polyvidon-Iodine on the infected cornea and Methods and Results cryocoagulation circular at limbus. Results: Although a therapy with topical Amphotericin B Case 1 and systemic lyposomal Amphotericin B was applied by the A 21-year old male, who used monthly soft contact lenses for first case the infection progressed to an endophthalmitis. 5 years, initially reported to our department’s clinic with pain, Unfortunately an enucleation was unavoidable. The multiple conservative antifungal therapy in the second case photophobia and decreased vision in the right eye for one week was successful, and the corneal transplant remained free starting in October 2014. In his medical history there was no from new infiltrations. ocular surgery or trauma in the past. The visual acuity of the infected eye in the first case was 1 out of 10. Upon examination, Conclusion: We consider the fast diagnosis of multidrug we found a central corneal ulcer of 3.1 mm in diameter with resistance of great importance. Secondly, a penetrating irregular borders, slight infiltration, and a thinned cornea. A keratoplasty early on the course of the disease increases the hypopyon of 1.0 mm was evident. The left eye showed no chances of a successful outcome. abnormalities. Our initial diagnosis was a contact lens associated keratitis. The patient was treated with topical eye drops consisting of Moxifloxacin, Gentamicin and Dexamethasone Keywords: Fusarium keratitis; Keratoplasty à chaud; every hour around the clock. Repeat corneal cultures were Multiresistance; Natamycin performed which initially revealed Staphylococcus epidermidis, although the contact lens culture showed the existence of Enterococcus casseliflavus, Corynebacterium species and © Under License of Creative Commons Attribution 3.0 License | This article is available from: http://dx.doi.org/10.21767/2471-8300.100009 1 Journal of Eye & Cataract Surgery 2016 ISSN 2471-8300 Vol.2 No.1:9 Candida lusitaniae. Unfortunately, the epithelial disease Itraconazol >8 μg/ml recurred and the patient reported once again to the hospital 15 days later. Upon examination, he was diagnosed with extensive At first, the patient recovered well from the surgery and epithelial edema, hypopyon and corneal infiltrate. The patient maintained a clear anterior chamber and corneal graft tissue. underwent a biopsy of corneal epithelium. The biopsy results The antibiotic regime constisted of topical Voriconazole eye were negative for Acanthamoeba and Fungi. Therefore, a drops every hour, Voriconazole 200 mg i.v. twice a day and oral corneal collagen crosslinking with Riboflavin and a dose of UV-A Doxycyclin 100 mg once a day. However, two weeks later, light of 3 mW / cm2 were applied twice for 30 minutes. This recurrent corneal endothelial deposits and stromal edema therapy resulted in a slight improvement of the patient´s began to develop in the center of the graft (Figure 1), followed condition. The patient was further treated with a combination by the appearance of cells and hypopyon in the anterior therapy. It consisted of: Polyhexanid 0.02% and chamber. The patient underwent repeat injections of Propamidinisoethinat 0.1% eye drops every two hours around Amphotericin B into the anterior chamber combined with the clock; Vancomycin eye drops 5 times a day; Neomycin/ corneal abrasion one month after the keratoplasty. Cultures Polymycin eye drops 5 times a day; Fluconazole 200 mg and from a biopsy of the excised cornea once again revealed the Doxycyclin 100 mg oral therapy once a day. Despite the same Fusarium species. An intense local therapy with prescribed therapeutic schema, the ocular findings worsened. Amphotericin B eye drops every half hour around the clock and Visual acuity declined to light perception. The clinical findings lyposomal Αmphotericin B 240 mg i.v. resulted in no correlated with the working diagnosis of fungal keratitis. In improvement of the eye condition. The patient developed a mild December 2014, the patient underwent a keratoplasty à chaud pharmaceutical hepatitis induced by Αmphotericin B. A week of the right eye. Postoperatively, 8 injections of Voriconazole 10 later the condition of the eye worsened; the corneal infiltration μgram/0, 1 ml were administered into the anterior chamber increased and hypopyon built up. The stromal and endothelial after placement of the graft. A further corneal biopsy showed a infection became turbid and progressed into a deep corneal fungal keratitis and the culture of the aqueous humour of the abscess and endophthalmitis. Due to multiple high resistance of puncture of the anterior chamber revealed Fusarium solani Fusarium solani to antimycotics with resultant failure of resistant to all the antimycotics. antibiotic therapy, an enucleation of the infected eye was Antifungal susceptibility testing was performed according to performed. The patient was discharged from the hospital on the guidelines of the European Committee on Antimicrobial Αmphotericin B and Gentamicin eye drops 5 times a day as well susceptibility Testing (EUCAST). The microbiological laboratory as on oral Voriconazole 200mg twice a day. used the minimum inhibitory concentrations (MIC) in order to determine the type and the amount of antifungal agent that the patient will receive, which in turn lowered the risk for microbial resistance to specific antifungal agents. Minimum inhibitory concentration (MIC) is defined as the lowest concentration of an antimicrobial agent that prevents the visible growth of a microorganism after overnight incubation. In the first case MIC of Amphotericin B appears to be the lowest one of all the tested antifungal agents. Therefore, Amphotericin B seemed to be the most appropriate local and systemic antimycotic therapy to minimize the possibility of recurrence of the fungal keratitis (Table 1). Table 1: Antifungal susceptibility testing through Microdilutiοns- Test (EUCAST) concerning the first patient. Antimycotic agent Minimal inhibitory concentrations (MIC) Figure 1: Recurrent corneal endothelial deposits one week Amphotericin B 2 μg/ml after the keratoplasty à chaud by the male patient with Casponfugin >8 μg/ml Fusarium-keratitis Anidulafungin >8 μg/ml Terbinfafin >32 μg/ml Case 2 Fluconazol >64 μg/ml Α 26-year old female patient, who also used monthly soft Voriconazole 4 μg/ml contact lenses, reported to the emergency room with mild eye Posaconazol
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