Voriconazole in the successful management of a case of Acanthamoeba-Cladosporium keratitis

Abstract

Purpose Acanthamoeba and fungal infections can be recalcitrant to therapy - more so when the deeper layers of the corneas are involved. We describe the diagnosis and successful management strategies employed in a case of deep keratitis due to co-infection with Acanthamoeba and Cladosporium sp. Observations Once the diagnosis of co-infection with both Acanthamoeba and Cladosporium was made, treatment was initiated with a combination of PHMB, chlorhexidine, natamycin, and voriconazole; to which the response was favorable. Signs of relapse with spread of the infection to the deeper plane and the presence of endothelial exudates were noted at 5 weeks. This was attributed to poor compliance. Though the response to re-initiation of therapy under direct supervision was once again favorable; it was only after the introduction of intrastromal voriconazole repeated at timely intervals that rapid and complete resolution was obtained. Conclusions Severe keratitis due to fungi or Acanthamoeba very often requires surgical intervention. Complete resolution with medical therapy was obtained only after the introduction of intrastromal voriconazole; thereby avoiding a therapeutic keratoplasty. The addition of voriconzole both topically and particularly intrastromally facilitated faster resolution as well as restricted the duration of therapy with more toxic drugs such as phmb and chlorhexidine.

A 5-Year Review of Coinfections in Acanthamoeba keratitis From South India

“…9 An analysis of the 20 documented case reports reported in the literature involving Acanthamoeba with fungi shows that 15 required keratoplasty for disease eradication. [10][11][12][13][14][15][16][17] Several recent studies have focused on coinfections in Acanthamoeba keratitis. A recent 10-year retrospective analysis by Singh et al 18 revealed that 37% of their Acanthamoeba cases were culture proven to be bacterial coinfections-the most common identified species being Staphylococcus.…”

“…9 An analysis of the 20 documented case reports reported in the literature involving Acanthamoeba with fungi shows that 15 required keratoplasty for disease eradication. 10–17…”

Assessment of genotypes, endosymbionts and clinical characteristics of Acanthamoeba recovered from ocular infection

“…Acanthamoeba and Malassezia coinfection has not been described in AK patients but M. restricta has infrequently caused fungal keratitis [ 62 ]. Other studies have reported keratitis due to co-infection of Acanthamoeba with fungi such as Cladosporium , Fusarium and Curvularia [ 23 , 63 , 64 ].…”

Poly(hexamethylene biguanide) hydrochloride (PHMB)-based materials: synthesis, modification, properties, determination, and application

“…Clinically, PHMB is widely used for managing infections and inflammations, such as in acute/chronic wound healing, burn care, and keratitis treatment. [227][228][229][230][231][232][233] The dosage of PHMB is the priority concern to ensure its non-toxicity and biosafety for clinical use. 234 Through conducting a randomized, doubleblind, placebo-controlled clinical trial on 61 patients who suffered from acute traumatic wounds, Payne and coworkers demonstrated that the early use of 0.04% PHMB showed a significant reduction of bacterial load.…”