Journal List > J Korean Ophthalmol Soc > v.57(3) > 1010524

TOOLS
Chung, You, Cho, and Ahn: Paecilomyces Keratitis: Cases in Korea and Literature Review
Original Article

J Korean Ophthalmol Soc 2016;57(3):390-398.

Published online: 3 September 2016

DOI: https://doi.org/10.3341/jkos.2016.57.3.390

Paecilomyces Keratitis: Cases in Korea and Literature Review

Sae Rom Chung, MD1, In Cheon You, MD1, 2, 3, Nam Chun Cho, MD, PhD1, 2, 3, Min Ahn, MD, PhD1, 2, 3

1Department of Ophthalmology, Chonbuk National University Medical School1, Jeonju, Korea

2Research Institute of Clinical Medicine, Chonbuk National University, Jeonju, Korea

3Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea

Address reprint requests to In Cheon You, MD, Department of Ophthalmology, Chonbuk National University Hospital, #20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea, Tel: 82-63-250-2581, Fax: 82-63-250-1960, E-mail: you2ic@daum.net

Received 11 August 2015       Revised 12 November 2015       Accepted 21 January 2016

Copyright © 2016 The Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To analyze the Paecilomyces keratitis cases in Korea and compare cases from foreign literature.

Methods

The records of 3 patients diagnosed with Paecilomyces keratitis at our hospital and other reported cases in Korea were evaluated to examine the predisposing factors, clinical aspects, antifungal therapy, therapeutic surgery, and visual outcome and compared with previously reported foreign cases.

Results

In Korea, 1 patient was female, 4 patients were male and had predisposing factors including prior corneal trauma or surgery, except 1 spontaneous occurrence. All 5 eyes of 5 patients had poor initial visual acuity, less than finger count, and deep corneal infiltration. The patients were treated with multiple topical and systemic antifungal treatments such as intracameral or intrastromal voriconazole injections and required evisceration and penetrating keratoplasty. However, the final outcomes were unsatisfactory. Previously reported cases from foreign literature also had predisposing factors such as corneal surgery, trauma, and soft contact lens use. They were resistant to antifungal therapy and eventually led to surgeries such as penetrating keratoplasty and the final outcomes were poor.

Conclusions

Frequently, Paecilomyces keratitis has direct risk factors and is resistant to many topical and systemic antifungal agents. In the majority of cases, therapeutic surgery was required and the final visual outcomes were poor. When Paecilomyces keratitis is suspected, we suggest aggressive therapy including intracameral and intravitreal injections of voriconazole in the initial treatment.

Keywords: Corneal ulcer, Fungal keratitis, Paecilomyces, Voriconazole

References

1. Pastor FJ, Guarro J. Clinical manifestations, treatment and outcome of Paecilomyces lilacinus infections. Clin Microbiol Infect. 2006; 12:948–60.
crossref
2. Yuan X, Wilhelmus KR, Matoba AY, et al. Pathogenesis and outcome of Paecilomyces keratitis. Am J Ophthalmol. 2009; 147:691–6.e3.
crossref
3. Byun DS, Yang HN, Cho HG, Cha YJ. A case of corneal ulcer caused by Paecilomyces in diabetic patient wearing soft contact lens. J Korean Ophthalmol Soc. 1987; 28:667–71.
4. Won JY, Shin JY, Hwang JH, Joo CK. A case of fungal keratitis caused by Paecilomyces lilacinus after penetrating keratoplasty. J Korean Ophthalmol Soc. 2014; 55:1384–7.
5. Monden Y, Sugita M, Yamakawa R, Nishimura K. Clinical experience treating Paecilomyces lilacinus keratitis in four patients. Clin Ophthalmol. 2012; 6:949–53.
crossref
6. Hirst LW, Choong K, Playford EG. Nontraumatic paecilomyces anterior segment infection: a pathognomonic clinical appearance. Cornea. 2014; 33:1031–7.
7. Yildiz EH, Ailani H, Hammersmith KM, et al. Alternaria and paecilomyces keratitis associated with soft contact lens wear. Cornea. 2010; 29:564–8.
crossref
8. Wu PC, Lai CH, Tan HY, et al. The successful medical treatment of a case of Paecilomyces lilacinus keratitis. Cornea. 2010; 29:357–8.
crossref
9. Arnoldner MA, Kheirkhah A, Jakobiec FA, et al. Successful treatment of Paecilomyces lilacinus keratitis with oral posaconazole. Cornea. 2014; 33:747–9.
crossref
10. McLintock CA, Lee GA, Atkinson G. Management of recurrent Paecilomyces lilacinus keratitis. Clin Exp Optom. 2013; 96:343–5.
crossref
11. Maier AK, Reichenbach A, Rieck P. Paecilomyces lilacinus keratitis. Ophthalmologe. 2011; 108:966–8.
12. Yildiz EH, Abdalla YF, Elsahn AF, et al. Update on fungal keratitis from 1999 to 2008. Cornea. 2010; 29:1406–11.
crossref
13. Keay LJ, Gower EW, Iovieno A, et al. Clinical and microbiological characteristics of fungal keratitis in the United States, 2001-2007: a multicenter study. Ophthalmology. 2011; 118:920–6.
crossref
14. Lee KH, Chae HJ, Yoon KC. Analysis of risk factors for treatment failure in fungal keratitis. J Korean Ophthalmol Soc. 2008; 49:737–42.
crossref
15. Kim KH, Kim MJ, Tchah H. Management of fungal ocular infection with topical and intracameral voriconazole. J Korean Ophthalmol Soc. 2008; 49:1054–60.
crossref
16. Al-Badriyeh D, Neoh CF, Stewart K, Kong DC. Clinical utility of voriconazole eye drops in ophthalmic fungal keratitis. Clin Ophthalmol. 2010; 4:391–405.
17. Sharma N, Sachdev R, Jhanji V, et al. Therapeutic keratoplasty for microbial keratitis. Curr Opin Ophthalmol. 2010; 21:293–300.
crossref
18. Cho SH, Park JW, Chung SK. The risk factor analysis of infectious corneal ulcers leading to eyeball removal. J Korean Ophthalmol Soc. 2008; 49:34–9.
crossref

Figure 1.
Slit-lamp photographs of Case 1. (A) At the initial visit, 4.5 × 4.5 mm sized epithelial defect with a 1.2 mm height hypopyon. (B) After 3 months, corneal lesion regressed with opacity at corneal center.
jkos-57-390f1.tif
Figure 2.
Slit-lamp photographs of Case 2. (A) At the initial visit, 6.0 × 7.0 mm sized epithelial defect with a 1.5 mm height hypopyon. (B) After 2 weeks, epithelial defect was healed with corneal opacity at the center and the infected eye became phthisis bulbi.
jkos-57-390f2.tif
Figure 3.
Slit-lamp photographs of Case 3. (A) At the initial visit, 8.0 × 7.0 mm sized epithelial defect with satellite lesion at the superior. (B) The patient rejected antifungal treatment and returned to hospital with corneal perforation.
jkos-57-390f3.tif
Table 1.
Data from 5 cases of Paecilomyces species keratitis in Korea
No Age (years) Gender Predisposing factor Initial V/A Location Depth Initial size (mm×mm) Hypopyon height (mm) Causative organism Surgical Tx Final V/A Hospital
1 69 F Spontaneous HM Central Deep 4.5 × 4.5 1.2 Paecilomyces species None 0.04 Chonbuk National University (2009)
2 69 M Exposure keratitis HM Central Deep 6.0 × 7.0 1.5 Paecilomyces lilacinus, Staphylococcos epidermidis None NLP Chonbuk National University (2011)
3 72 M Trauma NLP Central Deep 8.0 × 7.0 1.0 Paecilomyces species, Staphylococcus haemolyticus Evisceration NLP Chonbuk National University (2011)
4 67 M Penetrating keratoplasty FC50 cm Central Deep 3.8 × 6.0 − Paecilomyces lilacinus Penetrating keratoplasty 0.15 Catholic University (2013)
5 67 M Soft contact lens, diabetes mellitus, cataract operation FC50 cm Central Deep 1.5 × 1.5 − Paecilomyces species None − Choong-Ang University (1986)

V/A = visual acuity; Tx = treatment; F = female; M= male; HM = hand movement; NLP = no light perception; FC = finger count.

Table 2.
Data from Paecilomyces species keratitis outside Korea
Gender Predisposing factors Topical antifungal agents Systemic antifungal therapy Therapeutic surgery V/A
Yuan et al2 (n = 17) Male (41%)
1. Prior corneal condition or surgery (35%)
2. None (29%)
3. Soft contact lens wearer (24%)
4. Trauma (12%)
1. Natamycin 5% suspension
2. Amphotericin B 0.15% to 0.25%
3. Miconazole 1%
4. Voriconazole 0.2%
1. Oral voriconazole
2. Oral fluconazole
3. Oral ketoconazole
4. IV amphotericin B
1. Penetrating keratoplasty (47%)
2. Enucleation (6%)
1. FC or worse (35%)
2. 20/80 and 20/400 (12%)
3. 20/60 or better (53%)
Yuan et al2 Previous cases review: 20 papers (n = 25) Male (52%)
1. Trauma (36%)
2. Prior corneal condition or surgery (28%)
3. Soft contact lens wearer (24%)
4. None (12%)
1. Penetrating keratoplasty (68%)
2. Conjunctival flap (8%)
3. Enucleation (4%)
Pastor and Guarro1 (n = 15) (Review) Male (40%)
1. Ophthalmic surgery (33%)
2. Previous steroid use (27%)
3. Wearing of contact lenses (13%)
1. Amphotericin B
2. Miconazole
3. Flucytosine
4. Natamycin
1. Amphotericin B
2. Miconazole
1. Loss of vision (26.7%) (Enucleation included)
2. Recovered (46.6%)
3. Not reported (26.7%)
Monden et al5 (n = 4) Male (75%)
1. Diabetes, previous steroid use (50%)
2. Trauma (25%)
3. None (25%)
1. Fluconazole 0.1%
2. Miconazole 0.1%
3. Voriconazole 1%
1. IV fluconazole
2. IV miconazole
3. IV voriconazole
1. Lamellar keratoplasty (50%)
2. Penetrating keratoplasty (25%)
1. 20/100 or worse (50%)
2. 20/25 (25%)
3. 20/20 (25%)
Hirst et al6 (n = 22) Male (68%)
1. None (81%)
2. Minor trauma with no defect (14%)
3. Keratitis (5%)
1. Amphotericin B
2. Voriconazole
3. Natamycin
1. Amphotericin B
2. Itraconazole
3. Ketoconazole
4. Voriconazole
5. Terbinafine
1. Penetrating keratoplasty (59%)
2. Corneoscleral graft (41%)
3. Enucleation (27%)
4. Corneal patch graft (4.5%)
1. NLP (45.5%)
2. LP (4.5%)
3. FC (9%)
4. 6/18, 6/24, 6/60 (23%)
5. 6/9 or better (18%)
Yildiz et al7 (n = 3) Male (67%)
1. Wearing of contact lenses (100%)
1. Natamycin
1. Voriconazole
1. Penetrating keratoplasty (33%)
2. Perforated glue (33%)
1. 20/40 (66.7%)
2. 20/200 (33.3%)
Other previous cases (n = 4)* Male (75%)
1. Wearing of contact lenses (50%)
2. Previous steroid use (25%)
3. None (25%)
1. Voriconazole
2. Amphotericin
3. Natamycin
4. Miconazole
1. Voriconazole
2. Itraconazole
3. Posaconazole
 1. Penetrating keratoplasty (75%)
1. 20/200 or worse (50%)
2. 6/36 (25%)
3. 20/60 (25%)

V/A = visual acuity; IV = intravenous; FC = finger count; NLP = no light perception; LP = light perception.

* Other previous cases: Wu et al8, Arnoldner et al9, McLintock et al10, Maier et al11.

TOOLS
Similar articles