Diagnosis at first sight
Unusual etiology of keratitis in a patient with bullous queratopathy
Queratitis de etiología inusual en paciente con queratopatía bullosa
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=> "Martínez-Martínez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213005X18302787" "doi" => "10.1016/j.eimc.2018.09.014" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X18302787?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X19302515?idApp=UINPBA00004N" "url" => "/2529993X/0000003800000002/v1_202002060648/S2529993X19302515/v1_202002060648/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Diagnosis at first sight</span>" "titulo" => "Unusual etiology of keratitis in a patient with bullous queratopathy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "84" "paginaFinal" => "85" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Cristina Gaona-Álvarez, Carmen González-Velasco, Fernando Morais-Foruria, Ana Alastruey-Izquierdo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Cristina" "apellidos" => "Gaona-Álvarez" "email" => array:1 [ 0 => "cristinaega@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Carmen" "apellidos" => "González-Velasco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Fernando" "apellidos" => "Morais-Foruria" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Ana" "apellidos" => "Alastruey-Izquierdo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Sección de Microbiología, Hospital de Mérida, Mérida, Badajoz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital de Mérida, Mérida, Badajoz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Micología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Queratitis de etiología inusual en paciente con queratopatía bullosa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 657 "Ancho" => 903 "Tamanyo" => 53088 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Central leukoma after abscess and stromal and endothelial oedema due to bullous keratopathy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">This was an 87-year-old male with type 2 diabetes who had had bilateral cataract surgery at the age of 78. He presented with pseudophakic bullous keratopathy and recurrent corneal ulcers in his right eye. Four months earlier, he had had an amniotic membrane transplant with therapeutic contact lens placement, and been prescribed anti-oedema and cycloplegic eye drops, one drop/8<span class="elsevierStyleHsp" style=""></span>h, artificial tears as required and tobramycin eye drops, one drop/day. The patient consulted with severe stabbing pain in his right eye. Examination revealed normal intraocular pressure, conjunctival hyperaemia, corneal opacity and mild eyelid oedema. Biomicroscopy showed a central corneal abscess of 1.4<span class="elsevierStyleHsp" style=""></span>mm in diameter, hypopyon, severe hyperaemia and corneal oedema. As infectious keratitis was suspected, tobramycin was replaced by fortified vancomycin and ceftazidime eye drops. Two days later, a greater inflammatory reaction, increased turbidity in the anterior chamber and slightly superior hypopyon were observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A sample was taken for microbiological culture by scraping the edges and base of the abscess with a scalpel blade.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical course</span><p id="par0010" class="elsevierStylePara elsevierViewall">After 72<span class="elsevierStyleHsp" style=""></span>h of incubation, the bacteriological culture was negative. In Sabouraud agar at 30<span class="elsevierStyleHsp" style=""></span>°C, cottony, cream-coloured colonies grew, darkening to dark brown after several weeks. Microscopic observation with lacto-fuchsin showed thin septate hyphae with intercalary chlamydospores and pycnidia containing conidia (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Mycotic keratitis was diagnosed and intrastromal and intracameral voriconazole (50<span class="elsevierStyleHsp" style=""></span>μg/0.1<span class="elsevierStyleHsp" style=""></span>ml) applied, with 200<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h voriconazole also prescribed orally and one drop/h topically. We began to see clinical improvement, with disappearance of the hypopyon four days later and reduction of the abscess and perilesional infiltrate after two weeks. Oral voriconazole was continued for two months and topical voriconazole for a further month, and by three months the infection was completely resolved.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The strain was sent to the <span class="elsevierStyleItalic">Centro Nacional de Microbiología</span> (CNM) [Spanish Centre for Microbiology], where <span class="elsevierStyleItalic">Didymella glomerata</span> (formerly <span class="elsevierStyleItalic">Phoma glomerata</span>) was identified by sequencing the internal transcribed spacer (ITS) region. The sequences were analysed (SeqMan Pro, Lasergene) and compared with databases (GenBank®, MycoBank and CNM). The antifungal activity testing following the EUCAST 9.3 protocol for filamentous fungi showed MIC (μg/ml) of 0.007 to anidulafungin, 0.06 to itraconazole, isavuconazole and micafungin, 0.03 to posaconazole, 0.12 to voriconazole and 0.25 to amphotericin B, terbinafine and caspofungin.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comments</span><p id="par0025" class="elsevierStylePara elsevierViewall">Fungal keratitis is rare in temperate climates, accounting for less than 10 % of keratitis cases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The main aetiological agents belong to the genera <span class="elsevierStyleItalic">Fusarium</span>, <span class="elsevierStyleItalic">Aspergillus</span>, <span class="elsevierStyleItalic">Curvularia</span> and <span class="elsevierStyleItalic">Candida</span>.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The species of the genus <span class="elsevierStyleItalic">Phoma</span> are ubiquitous dematiaceous fungi, normally present in plants, soil, water and organic matter. They are common phytopathogens, but only certain species have been associated with animal and human disease.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> There are very few publications on infection in humans, and what there is mainly describes subcutaneous mycoses<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> and, to a lesser extent, eye infections.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Eye trauma,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8</span></a> contact lenses<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> and ocular surface disease are risk factors for fungal keratitis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is also associated with bullous keratopathy, diabetes, eye surgery and prolonged corticosteroid therapy or antibiotics.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In our case, the patient had diabetes and bullous keratopathy, in addition to amniotic membrane transplantation and therapeutic contact lens. The bullous keratopathy was probably the main reason for acquiring the infection, as the rupture of corneal bullae would facilitate the access of microorganisms.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The positive corneal scraping mycological culture and the rapid response to treatment indicate that the sample was representative of the infectious process, negating the need for biopsy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Voriconazole has excellent ocular penetration and good activity against filamentous fungi which normally cause keratitis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,9</span></a> which was why it was chosen in our case. There are no breakpoints for the clinical categories of <span class="elsevierStyleItalic">Phoma</span> spp. to antifungals as they are not common human pathogens, and nor is the inoculum for antifungal activity testing standardised. However, we decided to continue voriconazole due to its low MIC and the favourable progress the patient was making. The resolution of the infection confirms the correct choice of antifungal. Moreover, the clinical improvement after intrastromal and intracameral application demonstrates the suitability of this route of administration.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Plasma voriconazole levels were not monitored due to good treatment response and absence of toxicity and adverse effects.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinical suspicion of fungal keratitis in patients with risk factors facilitates the early establishment of adequate treatment, which improves the prognosis. As <span class="elsevierStyleItalic">Phoma</span> spp. is rarely isolated in clinical practice, we highlight the utility of molecular diagnosis for identification.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have not received any funding for this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical course" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Comments" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gaona-Álvarez C, González-Velasco C, Morais-Foruria F, Alastruey-Izquierdo A. Queratitis de etiología inusual en paciente con queratopatía bullosa. Enferm Infecc Microbiol Clin. 2020;38:84–85.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 657 "Ancho" => 903 "Tamanyo" => 53088 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Central leukoma after abscess and stromal and endothelial oedema due to bullous keratopathy.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 678 "Ancho" => 905 "Tamanyo" => 98488 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Microscopic view (staining with lacto-fuchsin, ×400). 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 2 | 4 |
| 2024 October | 28 | 8 | 36 |
| 2024 September | 41 | 13 | 54 |
| 2024 August | 35 | 9 | 44 |
| 2024 July | 35 | 5 | 40 |
| 2024 June | 26 | 5 | 31 |
| 2024 May | 29 | 3 | 32 |
| 2024 April | 34 | 14 | 48 |
| 2024 March | 35 | 19 | 54 |
| 2024 February | 25 | 9 | 34 |
| 2024 January | 53 | 6 | 59 |
| 2023 December | 50 | 8 | 58 |
| 2023 November | 46 | 8 | 54 |
| 2023 October | 70 | 12 | 82 |
| 2023 September | 27 | 2 | 29 |
| 2023 August | 33 | 2 | 35 |
| 2023 July | 36 | 6 | 42 |
| 2023 June | 64 | 4 | 68 |
| 2023 May | 74 | 7 | 81 |
| 2023 April | 61 | 2 | 63 |
| 2023 March | 63 | 5 | 68 |
| 2023 February | 49 | 2 | 51 |
| 2023 January | 85 | 1 | 86 |
| 2022 December | 49 | 8 | 57 |
| 2022 November | 34 | 3 | 37 |
| 2022 October | 33 | 8 | 41 |
| 2022 September | 40 | 9 | 49 |
| 2022 August | 42 | 9 | 51 |
| 2022 July | 29 | 6 | 35 |
| 2022 June | 22 | 7 | 29 |
| 2022 May | 22 | 9 | 31 |
| 2022 April | 34 | 6 | 40 |
| 2022 March | 34 | 18 | 52 |
| 2022 February | 27 | 8 | 35 |
| 2022 January | 63 | 22 | 85 |
| 2021 December | 21 | 12 | 33 |
| 2021 November | 13 | 7 | 20 |
| 2021 October | 17 | 10 | 27 |
| 2021 September | 16 | 10 | 26 |
| 2021 August | 32 | 9 | 41 |
| 2021 July | 13 | 7 | 20 |
| 2021 June | 18 | 8 | 26 |
| 2021 May | 23 | 8 | 31 |
| 2021 April | 38 | 8 | 46 |
| 2021 March | 16 | 10 | 26 |
| 2021 February | 11 | 8 | 19 |
| 2021 January | 15 | 9 | 24 |
| 2020 December | 14 | 9 | 23 |
| 2020 November | 19 | 8 | 27 |
| 2020 October | 8 | 10 | 18 |
| 2020 September | 15 | 6 | 21 |
| 2020 August | 16 | 17 | 33 |
| 2020 March | 2 | 0 | 2 |
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