A super-infection in the cornea caused by Stemphylium, Acremonium, and α-Streptococcus

Abstract

BackgroundPolymicrobial keratitis with fungus and bacteria can lead to blindness and is challenging to treat. Here, we introduce a case of fungal keratitis caused by two different strains in addition to definite bacterial super-infection caused by an α-Streptococcus sp., and describe the importance of microscopic examination.Case presentationA 74-year-old woman, who had a past history of infection with leprosy, presented with conjunctival hyperaemia, pain, and corneal opacity in her right eye. Under the presumptive diagnosis of infectious keratitis, corneal scrapings were stained by various reagents and inoculated on several agar plates. Microscopic findings of the scrapings revealed fungi and a small number of Gram-positive cocci. Multiple anti-fungal therapies with levofloxacin ophthalmic solution were administered. Although empiric treatment was initially effective, keratitis recurred 10 days after its initiation. Repeated corneal scraping revealed an abundance of Gram-positive chain cocci and a small amount of fungi, resulting in the switching of an antibiotic medication from levofloxacin to moxifloxacin and cefmenoxime. Keratitis resolved gradually after the conversion. Stemphylium sp., Acremonium sp., and α-Streptococcus sp. were simultaneously isolated from the corneal scrapings.ConclusionsTo the best of our knowledge, this is the first case of fungal keratitis caused by Stemphylium sp., and also the first case of super-infection in the cornea caused by two different fungi and one bacterium. Microscopic examination of the corneal scrapings was beneficial in rapid decision of changing to appropriate drug according to the dominancy of pathogenicity.

Acremonium keratitis: Risk factors, clinical characteristics, management, and outcome in 65 cases

“…Other risk factors which have been reported are previous use of steroids or long-term broad-spectrum antibiotics, poor ocular surface, reduced corneal sensation, lagophthalmos, and contact lens use, especially for prolonged hours. [ 17 ] Simmons et al ,[ 18 ] in 1986, isolated Acremonium along with other fungi in extended contact lenses, especially those with higher water content. Surgical procedures such as cataract surgery may cause suppression of systemic and local immunity, thereby facilitating the growth of opportunistic infections.…”

“…Polymicrobial infections, that is, the coexistence of fungus and bacteria are not uncommon. There have been case reports where Acremonium has been found coexistent with Stemphylium species[ 17 ] and with previous history of herpetic keratopathy. [ 36 ] In our series, there was evidence of coexistence with Staphylococcus , Pseudomonas , Corynebacterium , and coagulase-negative Staphylococcus , for which antibiotics in the form of fluoroquinolone were prescribed wherever required as mentioned before.…”

Clinical diagnosis and treatment of rare painless keratitis caused by three pathogens: clinical practice and experiential discussion

“…Our first choice was gatifloxacin because—in addition to the above factors—its ability to permeate into the eyes is much greater than that of the commonly used levofloxacin; moreover, its half-life is longer than that of moxifloxacin. 22 We instructed the patient to continue gatifloxacin until the end of topical glucocorticosteroid therapy to prevent the secondary growth of other bacteria. After viral infection, anterior uveitis can be triggered in the cornea. To prevent formation of a posterior synechia, we prescribed 5 mg/mL compound tropicamide eye drops (twice per day); these were continued until the end of loteprednol treatment (a type of glucocorticosteroid) and contributed to the good corrected vision outcome of our patient. When treating triple corneal infection, a full course of drug treatment with the full dose must be performed; an average treatment time of more than 28 days has been reported previously 5,7,23 and was used for treatment of our patient. Given the financial situation of our patient, we did not perform reverse transcriptase quantitative PCR after herpes simplex virus PCR to detect whether the herpes simplex virus DNA was indicative of residual antigen or active infection.…”

“…Our first choice was gatifloxacin because-in addition to the above factors-its ability to permeate into the eyes is much greater than that of the commonly used levofloxacin; moreover, its half-life is longer than that of moxifloxacin. 22 We instructed the patient to continue gatifloxacin until the end of topical glucocorticosteroid therapy to prevent the secondary growth of other bacteria. 6.…”

Mancha gris de la hoja del tomate: identificación, biología y genómica del agente etiológico

“…S. botryosum ha sido asociado a alrededor de 168 especies vegetales 25 , describiéndose como patógeno de, por ejemplo, espárrago 81 , alfalfa 82 y espinaca 83 , y como endófito de Chenopodium album 84 ; S. lycopersici ha sido asociado a alrededor de 47 especies vegetales 25 , describiéndose como patógeno de, por ejemplo, papa 85 Finalmente, en un caso excepcional, una especie de Stemphylium fue aislada de una queratitis polimicrobiana en humano; sin embargo, cabe mencionar que el paciente presentaba el tejido ocular inmunocomprometido 91 .…”