A case of fungal keratitis caused by Scopulariopsis brevicaulis: treatment with antifungal agents and penetrating keratoplasty.

Abstract

A case of fungal keratitis caused by Scopulariopsis brevicaulis following a penetrating eye injury is described. Treatment A corneal scrape revealed a few pus cells and later on culture yielded Scopulariopsis brevicaulis, confirming the previous report. An anterior chamber tap showed numerous pus cells but no organisms. Blood cultures were negative. The sensitivities of the organism were not available initially, but it was thought that treatment with amphotericin should be continued.As endophthalmitis was suspected; amphotericin was instilled into the anterior chamber at the time of the tap at a dose of 1-25 ,ig in 0 1 ml. This was calculated as 1/4 of the accepted intravitreal dose.1-' Topical steroids were stopped and hourly amphotericin 0-5% drops and cyclopentolate 1% drops three times a day continued. In addition, intravenous amphotericin 0-25 mg/ kg daily was given. After an initial improvement the hypopyon then increased and the cornea became more cloudy. On microbiological advice a new antifungal drug, itraconazole (Jansen Pharmaceuticals), was added at an initial dose of 200 mg twice a day orally for 24 hours, reducing to a maintenance dose of 100 mg twice a day. The clinical condition deteriorated further, and an emergency keratoplasty (8-5 mm donor button, with removal of an 8-0 mm disc of cornea, including all the involved cornea) was performed. Histological examination confirmed the mycotic keratitis with isolation of Scopulariopsis brevicaulis. Following keratoplasty dexamethasone 0-1% drops four times a day were given and the topical amphotericin 0(5% drops were reduced to four times daily. Intravenous amphotericin was stopped and oral itraconazole continued for three days.The graft cleared and has remained transparent, with a visual acuity of 6/9 with a contact lens. Later the Mycological Reference Laboratory showed the organism was resistant to amphotericin B at 20 [tg/ml but sensitive to itraconazole 2-0 [tg/ml.

Orbital apex syndrome due to scopulariopsis: a rare case report

“…5 Other studies have also suggested that the organism may be resistant to amphotericin B. [8][9][10] In contrast with previously described patients with Scopulariopsis species infection, our patient responded very well to intravenous amphotericin B, suggesting that in vitro susceptibility testing of imidazole might not correlate with clinical outcome.…”

“…To our knowledge, scopulariopsis has not previously been identified in the literature as a cause of orbital infection, although prior reports have associated Scopulariopsis with endophthalmitis and keratitis. 8 The optimal antimicrobial regimen for treating scopulariopsis infection is unknown. Results from in vitro susceptibility test vary widely, but the organism is often highly resistant to usual array of agents used to treat systemic fungal infections.…”

Current Perspectives on Ophthalmic Mycoses

“…Oral fluconazole therapy, in association with topical natamycin and intracameral amphotericin B and various surgical measures, resulted in eradication of corneal infection due to Colletotrichum graminicola (326). A combination of ketoconazole and amphotericin B therapy and keratoplasty resulted in a favorable outcome of posttraumatic keratitis due to Scopulariopsis brevicaulis in one patient (307). A common problem reported by all those who have had to treat Pythium insidiosum keratitis is that it is not sensitive to any of the currently available antifungals; wide surgical excision including penetrating keratoplasty has been advised for such patients, with enucleation or evisceration being required in patients who fail to respond to these measures (22,156,381,411).…”

Fungal Keratitis due to <i>Scopulariopsis</i><i>brevicaulis</i> in an Eye Previously Suffering from Herpetic Keratitis

“…brevicaulis, the causative agent of the corneal ulcer de scribed, has only once been reported as the cause of this pathology in man [4]. It is classified as a saprophyte o f the soil [5] and is more commonly found to be the cause of nail infections [6], Evidently, in our case, HSV I favoured the colonization of the mycete.…”