A Report of Five Cases of Mixed Candida and Bacterial Keratitis

Hoon Yang Young; Cheon You In

doi:10.3341/jkos.2013.54.5.818

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Young and In: A Report of Five Cases of Mixed Candida and Bacterial Keratitis

Original Article

J Korean Ophthalmol Soc 2013;54(5):818-822.

Published online: 7 September 2013

DOI: https://doi.org/10.3341/jkos.2013.54.5.818

A Report of Five Cases of Mixed Candida and Bacterial Keratitis

Hoon Yang Young, MD, Cheon You In, MD

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

Address reprint requests to In Cheon You, MD Department of Ophthalmology, Chonbuk National University Hospital #20 Geonji-ro, Deokjin-gu, Jeonju 561-712, Korea Tel: 82-63-250-1996, Fax: 82-63-250-1960, E-mail: You2ic@paran.com

Received 3 August 201219 October 2012 Accepted 25 February 2013

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 report the clinical manifestations and prognoses in 5 cases of mixed Candida and bacterial keratitis and pres-ent a literature review on mixed fungal and bacterial keratitis.

Case summary

Five eyes of 5 patients (1 male, 4 female) diagnosed as mixed Candida and bacterial keratitis by corneal smear and culture were included in the present study. Patient mean age was 62.80 years. All patients had preexisting ocu-lar or systemic conditions as predisposing factors for mixed Candida and bacterial keratitis. The most common Candida species isolated was Candida albicans (3 eyes, 60%), while Staphylococcus (3 eyes, 60%) was the most common mixed bacterial species. The average size of ulceration was 7.02 mm². In 2 eyes (40%), the lesions were located at the corneal center. The depth of the infiltration was significant in all cases, and hypopyon was present in 2 eyes (40%). On the initial visit, the visual acuity was counting fingers or worse in all cases. Four eyes (80%) unresponsive to the topical and systemic treatment underwent surgical intervention but only 1 eye (20%), which had responded to the topical and systemic treat-ment, showed acuity improvement of more than 1 line on the final visit.

Conclusions

In managing chronically compromised cornea, the possibility of mixed infections with Candida and bacterial organisms should be considered as keratitis shows poor prognosis.

Keywords: Bacteria, Candida species, Clinical aspect, Mixed keratitis, Prognosis

References

1. Hassan HM, Papanikolaou T, Mariatos G, et al. Candida albicans keratitis in an immunocompromised patient. Clin Ophthalmol. 2010; 4:1211–5.

2. Sun RL, Jones DB, Wilhelmus KR. Clinical characteristics and outcome of Candida keratitis. Am J Ophthalmol. 2007; 143:1043–5.

3. Ahn M, Yoon KC, Ryu SK, et al. Clinical aspects and prognosis of mixed microbial (bacterial and fungal) keratitis. Cornea. 2011; 30:409–13.

4. Kim JH, Shin HH, Song JS, Kim HM. Infectious keratitis caused by Stenotrophomonas maltophilia and yeast simultaneously. Cornea. 2006; 25:1234–6.

5. Kim JY, Yoon KC, Park YG, et al. Age-related clinical analysis of infectious keratitis in two tertiary centers. J Korean Ophthalmol Soc. 2010; 51:927–34.

6. Sun HJ, Lee JY, Kim SY, Jung MS. Clinical features of infectious keratitis in west coast area of chungcheongnam-do, Korea. J Korean Ophthalmol Soc. 2010; 51:658–63.

Figure 1.

Case 1. (A) At the initial visit, the left eye showed 6.3 mm² sized epithelial defect with deep stromal infiltration. (B) After 2 weeks, amniotic membrane transplantation was done. (C) After 1 year, corneal perforation developed at the site of the ulceration, so corneal button graft was done on the site of corneal perforation site.

Figure 2.

Case 2. (A) At the initial visit, the left eye showed 2.3 mm² sized epithelial defect with deep stromal infiltration. (B) After 6 months of antifungal and antibiotic treatment, corneal lesion regressed with opacification.

Figure 3.

Case 3. The left eye showing 4.5 mm² sized epi-thelial defect, associated deep stromal infiltration, hypopyon and multiple filaments at the initial visit.

Table 1.

Data from 5 cases of mixed infection with Candida species and bacterial keratitis

No	Age	Gender	Delay time to Definitive Tx (days)	Ocular history	Systemic disease	Initial V/A	Location	Depth	Initial size (mm²)	Hypopyon height (mm)	n Causative organism	Surgical Tx	Final V/A
1	70	F	35	Herpetic keratitis	None	FC	Central	Deep	6.3	None	Candida tropicalis, Streptococcus viridans	AMT, sclera graft, corneal button graft	LP
2	39	F	30	Unknown (cataract surgery)	Down syndrome	FC	Paracentral	Deep	2.3	None	Candida albicans, Staphylococcus haemolyticus, Streptococcus parasanguis	None	20/400
3	69	F	15	Herpetic keratitis	DM, CVA	FC	Paracentral	Deep	4.5	1.0	Candida albicans, Staphylococcus haemolyticus	Intracameral voriconazole, PKP	FC
4	69	F	10	Exposure keratitis Antiglaucoma eyedrop	Leprosy, HTN	NLP	Paracentral	Deep	40.0	4.0	Candida parapsilosis, Staphylococcus aureus	AMT, corneal button graft, tectonic KP, tarsorrhaphy PKP	NLP
5	67	M	80	Herpetic keratitis	None	LP	Central	Deep	18.0	None	Candida albicans, Pseudomonas aeruginosa	Conjunctival flap	NLP

Tx = treatment; V/A = visual acuity; DM = diabetes mellitus; CVA = cerebrovascular accident; HTN = hypertension; FC = finger count; LP = light perception; NLP = no light perception; AMT = amniotic membrane transplantation; PKP = penetrating keratoplasty.

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