Infectious crystalline keratopathy caused by <em>Cladosporium</em> sp. after penetrating keratoplasty: a case report

Abstract

BackgroundInfectious crystalline keratopathy is a rare, progressive infection characterized by the insidious progression of branches and crystalline corneal opacities with minimal or no inflammation. This case report describes the evolution of an infectious crystalline keratopathy caused by Cladosporium sp., which developed after tectonic keratoplasty in a patient with a history of ocular trauma.Case presentationA 40-year-old Brazilian male was the victim of firework-induced trauma to the left eye, which resulted in a corneal laceration that could not be sutured as well as a severe traumatic cataract. The patient underwent penetrating keratoplasty and phacoemulsification. During postoperative follow-up, another therapeutic keratoplasty was required because unresponsive infectious keratitis was observed. The infiltrate’s characteristics were suggestive of infectious crystalline keratopathy; in particular, the infiltrate was insidious and progressive, and grayish-white branches appeared in the anterior corneal stroma. As different therapies were administered, inflammatory reactions ranging from mild to severe were observed. The infection was unresponsive to typical antifungal drugs. This lack of response most likely occurred due to steroid treatment and the diffuse corneal spread of an atypical microorganism, which was subsequently identified in culture as Cladosporium sp. After the second therapeutic keratoplasty, the patient’s eye integrity was successfully reestablished.ConclusionThis study likely provides the first report describing a case of infectious crystalline keratopathy caused by Cladosporium sp. This case emphasizes the clinical characteristics and outcome of this type of keratitis.

Successful Management of Fungal Keratitis Caused by Multidrug-Resistant Cladosporium Species Using Povidone-Iodine

“…5 There are only few case reports showing the successful management of the Cladosporium species with voriconazole. 1,3,6,7 Cheng et al 1 found the Cladosporium sp. infection clinically resistant to topical amphotericin B, natamycin, fluconazole, and oral ketoconazole but later treated successfully with topical voriconazole.…”

“…Cladosporium is a dematiaceous group of fungi that is ubiquitously seen in soil, plants, food, air, etc. 1–3 Cladosporium is also present in the conjunctiva as a normal flora. 4 Usually, fungi do not infect the intact corneal epithelium, but predisposing factors such as ocular trauma breach the normal barrier and increase their chance of infectivity.…”

“…5 The literature on Cladosporium keratitis is limited, and only a few case reports have shown the successful management of Cladosporium with voriconazole treatment. 3,6,7 In this article, we report a case of fungal keratitis caused by the Cladosporium species, which was found to be resistant to multiple drugs, including voriconazole, and which responded very well to topical povidone-iodine (PVI) 5%.…”

Infectious crystalline keratopathy: Management of three cases with different risk factors

“…In addition to its appearance after a penetrating keratoplasty, 3 other infectious crystalline keratopathy associated risk factors have been described, as are the topical steroids use, herpetic keratitis, neurotrophic keratopathy, topical anaesthesia abuse,3, 4 or systemic conditions that lead to any grade of immunosuppression 5 . In our cases, the use of topical steroids after the keratoplasties or in the bullous keratopathy, the existence of a chronic alcoholism associated with a neurotrophic ulcer, or the bullous keratopathy itself, would justify the appearance of the infectious crystalline keratopathy, as all these situations could compromise the local immune response.…”

“…Many microorganisms that cause crystalline keratopathy have been reported,2, 3, 4, 5, 6, 7, 8 although viridans-type streptococci are the most frequently isolated 3, 4, 9. The identification of Bacillus spp.…”