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A propósito de un caso" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 750 "Ancho" => 750 "Tamanyo" => 89096 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest CT image: several nodules and a lung mass are seen.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eneko Ceciaga Elexpuru, Jose Maria Arrinda Yeregui, Estibaliz Barastay Alberdi" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Eneko" "apellidos" => "Ceciaga Elexpuru" ] 1 => array:2 [ "nombre" => "Jose Maria" "apellidos" => "Arrinda Yeregui" ] 2 => array:2 [ "nombre" => "Estibaliz" "apellidos" => "Barastay Alberdi" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775320307314" "doi" => "10.1016/j.medcli.2020.08.009" "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/S0025775320307314?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621005076?idApp=UINPBA00004N" "url" => "/23870206/0000015700000008/v1_202110160801/S2387020621005076/v1_202110160801/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020621005106" "issn" => "23870206" "doi" => "10.1016/j.medcle.2020.09.012" "estado" => "S300" "fechaPublicacion" => "2021-10-22" "aid" => "5467" "copyright" => "Elsevier España, S.L.U." 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Una causa infrecuente de diplopia" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 997 "Ancho" => 900 "Tamanyo" => 110904 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A: T2-weighted FSE sequence axial section showing no significant alterations. B: Gradient sequence axial section, where a hypointense linear image is identified in the right posterior medial pons (red arrow). C: Axial 3D T1-weighted sequence section after contrast administration, showing that the hypointense lesion located in the pons visible in the gradient sequence captures contrast homogeneously and intensely (red arrow). D: Sagittal 3D T1-weighted sequence reconstruction after contrast administration, showing homogeneous uptake of the hypointense lesion located in the pons (location of the nucleus of the <span class="elsevierStyleSmallCaps">VI</span> cranial nerve), findings indicative of capillary telangiectasia (red arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sonia Osorio Aira, M. Margarita Rodríguez Velasco" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Sonia" "apellidos" => "Osorio Aira" ] 1 => array:2 [ "nombre" => "M. 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Gegúndez-Fernández, David Díaz-Valle" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Bárbara" "apellidos" => "Burgos-Blasco" "email" => array:1 [ 0 => "bburgos171@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "José A." "apellidos" => "Gegúndez-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "David" "apellidos" => "Díaz-Valle" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Clínico San Carlos, Departamento de Inmunología, Oftalmología y ORL, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Queratitis fúngica por <span class="elsevierStyleItalic">Purpureocillium lilacinum</span>: diagnóstico por microscopía confocal y correlación histopatológica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 425 "Ancho" => 1500 "Tamanyo" => 118319 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(<span class="elsevierStyleBold">A</span>) Slit lamp examination on admission, (<span class="elsevierStyleBold">B</span>) In vivo confocal microscopy shows filamentous structures in the deep corneal stroma, (<span class="elsevierStyleBold">C</span>) Histopathology of corneal button obtained 10 days after starting topical treatment, which shows septate hyphae overswarming the stroma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Paecilomyces</span> spp. are uncommon fungi with increased clinical relevance and resistant to usual treatment. <span class="elsevierStyleItalic">Purpureocillium lilacinum</span> (former <span class="elsevierStyleItalic">Paecilomyces lilacinus)</span> presents a special tropism for ocular structures. However, few cases have been reported worldwide.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> Diagnosis is based on culture of the fungus, usually growing well in routine media. Correct identification is essential due to different antifungal resistance among species.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of <span class="elsevierStyleItalic">P. lilacinum</span> keratitis with confocal and histologic findings, showing the correlation between them and the therapeutic challenge this infection poses.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 73 years-old female with no past ocular or general history underwent an uneventful cataract surgery. 48<span class="elsevierStyleHsp" style=""></span>h after surgery, she presented with redness and pain. Best corrected visual acuity (BCVA) was 20/40 and examination revealed a whitish infiltrate as well as mild anterior chamber inflammation and iridian nodules, but no epithelial defect nor hypopion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The B scan showed no vitreous cells. Corneal scraping was performed and she was empirically treated with vancomycin (25<span class="elsevierStyleHsp" style=""></span>mg/ml), ceftazidime (50<span class="elsevierStyleHsp" style=""></span>mg/ml) and voriconazole 1% every 2<span class="elsevierStyleHsp" style=""></span>h.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Microbiological investigations yielded no results. Due to no improvement with broad-spectrum treatment, confocal microscopy was performed, revealing extensive filamentary forms consistent with a filamentous keratitis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Based on the confocal microscopy findings, a new corneal scraping was performed and treatment was subsequently combined with topical natamycin q.i.d. and systemic voriconazole (200<span class="elsevierStyleHsp" style=""></span>mg).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Microbiological investigations persisted negative. Due to the progressive clinical worsening and apparent unresponsiveness to treatment, an emergency keratoplasty was required. Analysis of the patient's cornea revealed the presence of a branched filamentous fungus with spores (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C), being <span class="elsevierStyleItalic">Paecilomyces lilacinum</span> identified in the cultures.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After a second emergency keratoplasty due to a recurrence of the infection and four months of treatment, there was resolution of the infection and improvement of the symptoms. BCVA was 20/200 at the six months’ follow-up visit.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Purpureocillium lilacinum</span>-induced keratitis are rare, presenting a significant challenge for diagnosis and successful treatment. They cause aggressive infections, which develop resistance to multiple conventional antifungal drugs.</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">P. lilacinum</span> is usually isolated from corneal cultures, with quick growth of lilac colonies in the culture. In our case, because microbiological investigations were negative and the infection worsened, confocal microscopy was performed. This noninvasive technique is of great utility in deep infiltrates not accessible to corneal scrapings and in patients on antifungal treatment, which render the anterior stroma sterile while organisms continue to be present in the deep stroma. Confocal microscopy is accurate and reliable in the diagnosis of fungal keratitis with a sensitivity and specificity of 67% and 100%, respectively.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Although this technique did not determine the exact pathogen, it did provide valuable information in that the causative microorganism was a filamentous fungus, despite repeatedly negative culture results. In <span class="elsevierStyleItalic">P. lilacinum</span> the angle of fungal branching can vary from 30 degrees to 90 degrees.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> However, their septate, nonpigmented acute branching hyphae make them indistinguishable from other species on microscopic examination. To our knowledge, only one other case after penetrating keratoplasty has described this technique in <span class="elsevierStyleItalic">P. lilacinum</span> keratitis,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> so this is the first report in fungal keratitis of short evolution in a native cornea.</p><p id="par0050" class="elsevierStylePara elsevierViewall">When comparing the microbiological and histopathological findings, the sensitivity and specificity are found to be 94 and 78% in fungal infections.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Confocal microscopy's correlation with histologic features has not been described in <span class="elsevierStyleItalic">Paecilomyces</span> spp. keratitis. In our case, both confocal microscopy and pathology revealed the presence of a filamentous fungus with septate hyphae. Therefore, this the first report of a good correlation between the confocal and the pathology findings in these fungi.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Antifungal susceptibility testing should be performed because of its frequent resistance to antifungal agents. Although there is no universally accepted treatment, case reports show that the use of voriconazole or posaconazole may be the best initial approach and an effective antifungal treatment in cases poorly responsive to other therapies.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, <span class="elsevierStyleItalic">P. lilacinum</span> is a rare cause of fungal keratitis and its treatment is usually challenging, therefore early microorganism detection is necessary. We describe a <span class="elsevierStyleItalic">P. lilacinum</span>-induced keratitis diagnosed with in vivo confocal microscopy, which can be useful in cases where microbiological investigations yield no results and correlates well with histopathology findings.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 425 "Ancho" => 1500 "Tamanyo" => 118319 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(<span class="elsevierStyleBold">A</span>) Slit lamp examination on admission, (<span class="elsevierStyleBold">B</span>) In vivo confocal microscopy shows filamentous structures in the deep corneal stroma, (<span class="elsevierStyleBold">C</span>) Histopathology of corneal button obtained 10 days after starting topical treatment, which shows septate hyphae overswarming the stroma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathogenesis and outcome of paecilomyces keratitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "X. 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Messmer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1055/s-0032-1314986" "Revista" => array:6 [ "tituloSerie" => "Klin Monbl Augenheilkd" "fecha" => "2012" "volumen" => "229" "paginaInicial" => "696" "paginaFinal" => "704" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22833133" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015700000008/v1_202110160801/S2387020621005192/v1_202110160801/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015700000008/v1_202110160801/S2387020621005192/v1_202110160801/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621005192?idApp=UINPBA00004N" ]
Journal Information
Vol. 157. Issue 8.
Pages 398-399 (October 2021)
Vol. 157. Issue 8.
Pages 398-399 (October 2021)
Letter to the Editor
Purpureocillium lilacinum fungal keratitis: Confocal microscopy diagnosis and histopathology correlation
Queratitis fúngica por Purpureocillium lilacinum: diagnóstico por microscopía confocal y correlación histopatológica
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a Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
b Servicio de Oftalmología, Hospital Clínico San Carlos, Departamento de Inmunología, Oftalmología y ORL, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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