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.

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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.

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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.

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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.

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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.

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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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