Recurrent Lecythophora mutabilis keratitis and endophthalmitis after deep anterior lamellar keratoplasty

Therapeutic contact lens-related infection by a novel pathogenic fungus Coniochaeta hoffmannii-a case report

This study aims to report a rare instance of corneal decompensation brought on by Coniochaeta hoffmannii fungus invasion of a bandage contact lens (BCL). A 71-year-old man with pseudophakic bullous keratopathy (PBK) had BCL treatment for four months to symptomatically reduce pain and itching in his right eye. However, the patient unexpectedly lost his vision. The slit-lamp examination revealed an edematous cornea; the extensive direct inspection raised suspicion of BCL. For morphological characterization, the BCL extracted was inoculated onto 5% sheep blood agar and PDA. By Sanger sequencing method the isolate's genomic DNA was molecularly identified as C. hoffmannii.

Fungal keratitis caused by Coniochaeta mutabilis – a case report

We present a rare case of recalcitrant fungal keratitis caused by Coniochaeta mutabilis, successfully managed with a course of oral, topical, intrastromal, and intracameral antifungals. A 57-year-old male on their fourth week of treatment for presumed left herpes simplex keratitis presented to clinic with severe left-sided foreign body sensation after gardening in his yard. On examination, a white corneal plaque was observed at 8 o'clock, shown to be a dense collection of fungal hyphae on confocal microscopy. Corneal cultures revealed yeast-like cells, initially identified as Kabatiella zeae by matching 100% identity with K. zeae strains CBS 767.71 and CBS 265.32 in BLASTn search using the internal transcribed spacer (ITS) sequence. Treated for over four months with topical amphotericin B and oral voriconazole without improvement, recourse to intrastromal and intracameral amphotericin B injections, coupled with the application of cyanoacrylate glue to the lesion and a bandage contact lens, led to eventual resolution. The patient subsequently underwent cataract surgery, achieving a BCVA of 20/20 in the eye. Surprisingly, upon further sequence analyses of combined ITS and large subunit ribosomal ribonucleic acid (LSU) and investigation of the K. zeae German strain CBS 767.71, the organism was revealed to be Coniochaeta mutabilis (formerly Lecythospora mutabilis). This means that the correct name for CBS 767.71 and CBS 265.32 is C. mutabilis and should be corrected in the GenBank record to avoid misleading identification in the future. This case also underscores the urgent unmet need for improved molecular diagnostic modalities in the care of corneal infections.

Coniochaeta massiliensis sp. nov. Isolated from a Clinical Sampl28

The genus Coniochaeta belongs to the class Ascomycota and the family Coniochaetaceae. Some of the Coniochaeta species are plant and animal pathogens, while others are known to be primarily involved in human diseases. In the last few decades, case reports of human infections with Coniochaeta have increased, mainly in immunocompromised hosts. We have described and characterised a new species in the genus Coniochaeta, here named Coniochaeta massiliensis (PMML0158), which was isolated from a clinical sample. Species identification and thorough description were based on apposite and reliable phylogenetic and phenotypic approaches. The phylogenetic methods included multilocus phylogenetic analyses of four genomic regions: ITS (rRNA Internal Transcribed Spacers 1 and 2), TEF-1α (Translation Elongation Factor-1alpha), B-tub2 (β-tubulin2), and D1/D2 domains (28S large subunit rRNA). The phenotypic characterisation consisted, first, of a physiological analysis using both EDX (energy-dispersive X-ray spectroscopy) and Biolog^TM advanced phenotypic technology for fixing the chemical mapping and carbon-source oxidation/assimilation profiles. Afterwards, morphological characteristics were highlighted by optical microscopy and scanning electron microscopy. The in vitro antifungal susceptibility profile was characterised using the E-test^TM exponential gradient method. The molecular analysis revealed the genetic distance between the novel species Coniochaeta massiliensis (PMML0158) and other known taxa, and the phenotypic analysis confirmed its unique chemical and physiological profile when compared with all other species of this genus.

Post-traumatic Fungal Keratitis and Endophthalmitis Caused by Coniochaeta Hoffmannii with Late Recurrence following Therapeutic Full-thickness Penetrating Keratoplasty

BACKGROUND

To report a rare case of fungal keratitis and endophthalmitis due to Coniochaeta hoffmannii.

METHODS

Case report.

RESULTS

A 71-year-old immunocompetent male sustained a corneal laceration, traumatic cataract, and retinal detachment due to penetrating injury from a nail pulled from a wooden deck. The patient's postoperative course was complicated by infectious keratitis. Fungal cultures, DNA sequencing and analysis of the internal transcribed spacer sequence confirmed Coniochaeta hoffmannii. Topical and oral voriconazole treatments were initiated; however, due to impending perforation, a therapeutic corneal transplant was required. One year later, the patient developed a new corneal infiltrate at the graft-host junction: Corneal scrapings were culture positive for Coniochaeta hoffmannii. This was treated with topical and intrastromal voriconazole along with oral itraconazole 200 mg once daily for 8 months.

CONCLUSIONS

Coniochaeta hoffmannii may cause recalcitrant keratitis and endophthalmitis, which required longstanding antifungal treatment.

Multi-drug resistant Enterococcus faecium in late-onset keratitis after deep anterior lamellar keratoplasty: A case report and review of the literature

RATIONALE

Interface keratitis after lamellar keratoplasty is one of the causes of graft failure. We report the first case of microbiologically proven Enterococcus faecium infection following deep anterior lamellar keratoplasty (DALK) and review the available literature.

PATIENT CONCERNS

A 37-years-old Caucasian man presented with pain, redness and severe vision loss in his right eye. Five weeks before, he underwent DALK using the FEMTO LDV Z8 in the same eye for the surgical correction of keratoconus.

DIAGNOSES

Upon presentation, slit-lamp biomiscroscopy revealed corneal graft edema with multiple infiltrates located in the graft-host interface.

INTERVENTIONS

Therapeutic penetrating keratoplasty (PKP) was carried out in addition with cultures of the donor lenticule removal. Laboratory results isolated a multi-resistant Enterococcus faecium interface infection. According to the antibiogram, the patient was treated with systemic Tigecycline and Linezolid for 7 days.

OUTCOMES

During the following weeks, clinical features improved over time and no signs of active infection were visible seven months postoperatively.

LESSONS

Early PKP showed to be a good therapeutic option with great anatomic and functional outcomes.

A rare case of Lecythophora endogenous endophthalmitis: Diagnostic and therapeutic challenge

Fungal endogenous endophthalmitis (EE) secondary to contaminated intravenous fluid infusion is frequently seen in developing countries. Molds and yeasts are commonly implicated as the causative agents. Dematiaceous fungi such as Lecythophora have been linked to exogenous endophthalmitis but have never been reported to cause EE. We report a case of Lecythophora EE that was successfully managed with pars plana vitrectomy along with intravitreal and systemic voriconazole. Endogenous endophthalmitis (EE) is a potentially devastating intraocular infection caused by intraocular spread of pathogens through blood stream. It generally accounts for 2%–16% of all reported endophthalmitis cases.[1] Predisposing risk factors include diabetes mellitus, malignancies, intravenous drug use, organ abscess, immunosuppressive therapy, indwelling catheters, urinary tract infection, organ transplant, end-stage renal or liver disease, and endocarditis.[2] It may occur in patients with no overt signs of systemic infection, particularly in the setting of contaminated intravenous fluid infusion in a rural setting.[3] Among the three broad categories of pathogens responsible for EE-bacteria, yeast, and molds, cases caused by molds are most infrequent and have the worst outcomes.[4] While Candida and Aspergillus are the most common species among fungal causes of EE, Lecythophora has been rarely reported as a cause of endophthalmitis due to exogenous causes.[5678] We, herein, report a case of EE caused by Lecythophora species.

Current Concepts in the Management of Unique Post-keratoplasty Infections

As corneal transplantation has evolved, the spectrum of post-surgical infection has changed and often presents a diagnostic and therapeutic challenge. Lamellar techniques hold the potential of improved outcomes and decreased post-operative complications, however, they create a lamellar interface, which is a potential space for sequestration of infectious organisms. In addition, while keratoprosthesis offers vision to patients who are poor candidates for traditional keratoplasty, infectious complications can be severe and sight threatening. Although antimicrobials remain the mainstay of treatment, definitive management often requires surgical intervention.

Fungal interface keratitis by Candida orthopsilosis following deep anterior lamellar keratoplasty

A 39-year-old male patient underwent uncomplicated deep anterior lamellar keratoplasty due to keratoconus. On day 5 after surgery, small whitish infiltrates developed in the corneal interface. The diagnosis of fungal keratitis was made when the culture medium of the graft grew Candida after the surgical intervention. Despite intensive antimycotic treatment and irrigation of the interface, the infiltrates persisted and eventually enlarged. Therefore, revision surgery with penetrating keratoplasty was performed. Microbiological analysis showed Candida orthopsilosis in the culture of the excised graft button. Histopathological staining of the excised graft showed periodic acid-Schiff-positive and Grocott methenamine silver-positive clusters of yeast between Descemet's membrane and the deep corneal stroma with focal perforations through Descemet's membrane. The treatment of mycotic keratitis caused by C orthopsilosis is challenging. Antimycotic treatment was unsuccessful in this case. Progression of the keratitis and perforation of Descemet's membrane suggest that early surgical intervention by penetrating keratoplasty is required.