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Fungal keratitis caused by Colletotrichum spp. A presentation of case
Queratitis fúngica por Colletotrichum spp. A propósito de un caso
M. Morcillo Guardiola
, N. Hurtado Montalbán, J.A. Martínez Morales, M.P. Villegas Pérez, J. Miralles de Imperal Mora Figueroa
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Servicio de Oftalmologia, Hospital General Universitario Reina Sofía, Murcia, Spain
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Morcillo Guardiola, N. Hurtado Montalbán, J.A. Martínez Morales, M.P. Villegas Pérez, J. Miralles de Imperal Mora Figueroa" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Morcillo Guardiola" "email" => array:1 [ 0 => "nellymed03@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Hurtado Montalbán" ] 2 => array:2 [ "nombre" => "J.A." "apellidos" => "Martínez Morales" ] 3 => array:2 [ "nombre" => "M.P." "apellidos" => "Villegas Pérez" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Miralles de Imperal Mora Figueroa" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmologia, Hospital General Universitario Reina Sofía, Murcia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Queratitis fúngica por <span class="elsevierStyleItalic">Colletotrichum</span> spp. A propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figs. 1 and 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1v2.jpeg" "Alto" => 1258 "Ancho" => 827 "Tamanyo" => 124590 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Tree-shaped stromal infiltrates at onset.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The cornea can be affected by any species of fungus. Over 100 fungi have been identified as causing fungal keratitis (FK).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This disease is more frequent in tropical countries but is rare in cool and cold climates, even though in recent years FK has increased due to technical diagnostic developments as well as increased incidence.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The risk factors for FK are diverse<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>: chronic ocular surface disease, contact lenses, atopical disease, use of topical steroids, corneal surgery and diabetes mellitus among others, although in most cases ocular trauma is a part of the patient history.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The main pathogens causing FK are yeasts such as <span class="elsevierStyleItalic">Candida</span><a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> and filamented septated non-pigmented fungii such as <span class="elsevierStyleItalic">Fusarium</span> and <span class="elsevierStyleItalic">Aspergillus</span>.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors present an FK case caused by an unusual fungal species in ophthalmology such as <span class="elsevierStyleItalic">Colletotrichum</span> spp. P<span class="elsevierStyleItalic">olletotrichum</span> is a filamented septated and pigmented fungi, which parasites subtropical and tropical plants and is difficult to identify with culturing.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It can be observed under microscope with its characteristic canoe-shaped form.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical case</span><p id="par0025" class="elsevierStylePara elsevierViewall">Male, 23, without relevant personal history who visited the emergency section due to right eye (RE) traumatism caused by a lemon tree branch 48<span class="elsevierStyleHsp" style=""></span>h earlier.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Ophthalmological examination revealed visual acuity of one in both eyes. RE biomicroscopy showed moderate conjunctival hyperemia and upper temporal corneal erosion with whitish and arborescent stromal infiltrate, the central area of which stained under fluorescein. The anterior chamber exhibited a Tyndall of +/++ (<a class="elsevierStyleCrossRef" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Corneal sample was taken for culturing and Gram staining, while establishing treatment with broad spectrum and reinforced antibiotics: vancomycin 25<span class="elsevierStyleHsp" style=""></span>mg/ml and ceftazidime 50<span class="elsevierStyleHsp" style=""></span>mg/ml, alternating every hour.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following day, the Gram staining showed the pathogen organism as gram-positive. Agar Sabouraud culture exhibited fungi growth after 72<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0045" class="elsevierStylePara elsevierViewall">With said results at hand, topical treatment was established with amphotericin B at a concentration of 0.5<span class="elsevierStyleHsp" style=""></span>mg/ml every 4<span class="elsevierStyleHsp" style=""></span>h without respecting sleep, as well as tobramycin every 3<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0050" class="elsevierStylePara elsevierViewall">One week after obtaining the sample and having the confirmation of fungal keratitis, our laboratory sent the sample to the National Microbiology Center (Carlos III Health Institute in Majadahonda), which returned the results of minimum inhibiting concentrations determination: 5-fluorocytosine (128<span class="elsevierStyleHsp" style=""></span>μg/ml), amphotericin B (0.5<span class="elsevierStyleHsp" style=""></span>μg/ml) and itraconazole (1<span class="elsevierStyleHsp" style=""></span>μg/ml). Upon exhibiting sensitivity to amphotericin B, the same treatment pattern was maintained.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Three weeks later, biomicroscopy revealed slight conjunctival hyperemia with increasingly transparent and smaller corneal infiltrates. Due to this positive evolution, amphotericin B was reduced to one drop every 6<span class="elsevierStyleHsp" style=""></span>h, respecting sleep, and progressively reducing the treatment in the course of 6 more weeks up to suspension. Slit lamp exploration revealed upper temporal corneal leukoma, a vestige of the former disorder (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 3 and 4</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Three months after disorder onset, the pathogen was identified as <span class="elsevierStyleItalic">Colletotrichum</span> spp. by the Carlos III Health Institute.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Colletotrichum</span> is an infrequent cause of FK. Out of 125 FK cases diagnosed in the Bascom Palmer Institute in Florida in 1994, only one case (0.8%) was found to be caused by <span class="elsevierStyleItalic">Colletotrichum atramentum</span>.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Subsequently, another review covering the period from January 1990 to February 2001<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> in the same institution identified 10 cases of <span class="elsevierStyleItalic">Colletotrichum</span> (2.8%) out of 360 positive cultures for fungi, isolating <span class="elsevierStyleItalic">Gloeosporioides</span> and <span class="elsevierStyleItalic">Dematium</span>.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">FK caused by filamented fungi such as <span class="elsevierStyleItalic">Colletotrichum</span> are more frequent in tropical regions<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and in most cases affected normal eyes after corneal abrasion caused by some type of vegetal substance<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. These keratitis are generally central or paracentral with irregular, seesaw or arborescent edges accompanied by anterior stromal infiltrate. Occasionally, brown pigmentation appears in the ulcer substrate. The evolution of keratitis caused by <span class="elsevierStyleItalic">Colletotrichum</span> is slowly progressive in comparison with <span class="elsevierStyleItalic">Aspergillus</span> and <span class="elsevierStyleItalic">Fusarium</span>. For its identification by culturing, the most frequently used media are Saboraud dextrose agar (SDA), potato dextrose agar (PDA) and moderate yeast agar, and the optimum growth temperature is of 25<span class="elsevierStyleHsp" style=""></span>°C, characterized by the formation of conidia with appressorium and acervulum with mushrooms.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The cases reported herein represents the first reported positive culturing of <span class="elsevierStyleItalic">Colletotrichum</span> in our country. Even though our patient evolved positively with antifungal pharmacological treatments, in a high percentage of cases FK exhibits torpid evolution affecting visual acuity.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,5</span></a> Accordingly, early identification and immediate treatment is crucial for avoiding complications such as corneal perforation<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and endophthalmitis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which would require surgical intervention.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Despite the absence of consensus regarding the pharmacological treatment of FK, it has been determined in vitro<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> that <span class="elsevierStyleItalic">Colletotrichum</span> has greater sensitivity to clotrimazole followed by miconazole, lactones and amphotericin B.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> As in this case, other authors<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> have found that <span class="elsevierStyleItalic">Colletotrichum</span> is mainly sensitive to amphotericin B and also responds to natamycin.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Even though <span class="elsevierStyleItalic">Colletotrichum</span> continues to be a rare cause of FK, the authors believe that due to its potential severity it must be included in differential diagnostic for fungal corneal infections.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interests</span><p id="par0090" class="elsevierStylePara elsevierViewall">No conflict of interests has been declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres352624" "titulo" => array:3 [ 0 => "Abstract" 1 => "Case report" 2 => "Discussion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec334087" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres352625" "titulo" => array:3 [ 0 => "Resumen" 1 => "Caso clinico" 2 => "Discusion" ] ] 3 => array:2 [ "identificador" => "xpalclavsec334088" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-01-23" "fechaAceptado" => "2012-07-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec334087" "palabras" => array:3 [ 0 => "Fungal keratitis" 1 => "<span class="elsevierStyleItalic">Colletotrichum</span>" 2 => "Ocular trauma plant" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec334088" "palabras" => array:3 [ 0 => "Queratitis fúngica" 1 => "<span class="elsevierStyleItalic">Colletotrichum</span>" 2 => "Traumatismo ocular vegetal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Case report</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 23-year-old male with an unremarkable past medical history suffered an injury in the right eye two days prior to presentation due to a freak accident with a branch of a lemon tree. The slit-lamp examination showed a central corneal erosion with a white tree-shaped stromal infiltrate and Tyndall +/++ in anterior chamber. Cultivation of corneal scraping was positive for <span class="elsevierStyleItalic">Colletotrichum</span> spp. The patient responded favorably to topical amphotericin.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Colletotrichum</span> spp. is an uncommon cause of keratitis, usually secondary to corneal erosion caused by plant material and should be included in the differential diagnosis of fungal keratitis.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0025">Caso clinico</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Paciente varón de 23 años sin antecedentes personales de interés que acude por traumatismo con rama de limonero en ojo derecho hacía dos días. En la biomicroscopía se observaba una erosión corneal central, un infiltrado estromal arboriforme blanquecino y un tyndall +/++. El cultivo de raspado corneal fue positivo para <span class="elsevierStyleItalic">Colletotrichum</span> spp. El paciente respondió favorablemente a la anfotericina tópica.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Discusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Colletotrichum</span> spp. constituye una causa infrecuente de queratitis, secundaria generalmente a erosiones ocasionadas por productos de origen vegetal y debe ser incluido en el diagnóstico diferencial de las queratitis fúngicas.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Morcillo Guardiola M, Hurtado Montalbán N, Martínez Morales JA, Villegas Pérez MP, Miralles de Imperal Mora Figueroa J. Queratitis fúngica por <span class="elsevierStyleItalic">Colletotrichum</span> spp. A propósito de un caso. Arch Soc Esp Oftalmol. 2014;89:110–112.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figs. 1 and 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1v2.jpeg" "Alto" => 1258 "Ancho" => 827 "Tamanyo" => 124590 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Tree-shaped stromal infiltrates at onset.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figs. 3 and 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3v4.jpeg" "Alto" => 1252 "Ancho" => 827 "Tamanyo" => 104166 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Residual corneal leukoma after treatment with amphotericin B. gr3v4.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The changing spectrum of fungal keratitis in South Florida" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 3 | 3 | 6 |
| 2018 March | 1 | 3 | 4 |
| 2018 February | 10 | 1 | 11 |
| 2018 January | 3 | 1 | 4 |
| 2017 December | 11 | 0 | 11 |
| 2017 November | 7 | 1 | 8 |
| 2017 October | 17 | 1 | 18 |
| 2017 September | 11 | 3 | 14 |
| 2017 August | 11 | 2 | 13 |
| 2017 July | 25 | 2 | 27 |
| 2017 June | 16 | 2 | 18 |
| 2017 May | 17 | 18 | 35 |
| 2017 April | 30 | 39 | 69 |
| 2017 March | 28 | 5 | 33 |
| 2017 February | 24 | 3 | 27 |
| 2017 January | 19 | 1 | 20 |
| 2016 December | 34 | 2 | 36 |
| 2016 November | 17 | 3 | 20 |
| 2016 October | 31 | 10 | 41 |
| 2016 September | 52 | 5 | 57 |
| 2016 August | 21 | 2 | 23 |
| 2016 July | 18 | 2 | 20 |
| 2016 June | 18 | 3 | 21 |
| 2016 May | 11 | 11 | 22 |
| 2016 April | 15 | 2 | 17 |
| 2016 March | 19 | 3 | 22 |
| 2016 February | 13 | 8 | 21 |
| 2016 January | 12 | 14 | 26 |
| 2015 December | 21 | 10 | 31 |
| 2015 November | 16 | 7 | 23 |
| 2015 October | 26 | 2 | 28 |
| 2015 September | 25 | 5 | 30 |
| 2015 August | 7 | 8 | 15 |
| 2015 July | 13 | 1 | 14 |
| 2015 June | 11 | 3 | 14 |
| 2015 May | 20 | 5 | 25 |
| 2015 April | 17 | 6 | 23 |
| 2015 March | 18 | 3 | 21 |
| 2015 February | 30 | 1 | 31 |
| 2015 January | 22 | 6 | 28 |
| 2014 December | 30 | 7 | 37 |
| 2014 November | 19 | 3 | 22 |
| 2014 October | 29 | 8 | 37 |
| 2014 September | 57 | 16 | 73 |
| 2014 August | 5 | 3 | 8 |
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