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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 4  |  Page : 585-587
 

Keratitis by Paecilomyces lilacinus: A case report from Sub-Himalayan region


1 Department of Microbiology, IGMC, Shimla, Himachal Pradesh, India
2 Department of Ophthalmology, IGMC, Shimla, Himachal Pradesh, India

Date of Submission04-Jun-2014
Date of Acceptance24-Apr-2015
Date of Web Publication16-Oct-2015

Correspondence Address:
V Sharma
Department of Microbiology, IGMC, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.167329

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 ~ Abstract 

Paecilomyces lilacinus is a filamentous fungus found in soil and air, which is a rare cause of ocular infection. The majority of case reports involving P. lilacinus among healthy hosts are of endophthalmitis and keratitis. We report a rare case of keratomycosis by P. lilacinus, in an immunocompetent, which responded well to treatment with ketoconazole. Some species belonging to the genus Paecilomyces such as P. lilacinus generally shows a poor response to conventional antifungal drugs. Therefore, correct identification of clinical isolates to the species level is mandatory for the appropriate treatment of the disease.


Keywords: Keratitis, ketoconazole, Paecilomyces


How to cite this article:
Sharma V, Angrup A, Panwar P, Verma S, Singh D, Kanga A. Keratitis by Paecilomyces lilacinus: A case report from Sub-Himalayan region. Indian J Med Microbiol 2015;33:585-7

How to cite this URL:
Sharma V, Angrup A, Panwar P, Verma S, Singh D, Kanga A. Keratitis by Paecilomyces lilacinus: A case report from Sub-Himalayan region. Indian J Med Microbiol [serial online] 2015 [cited 2019 Dec 15];33:585-7. Available from: http://www.ijmm.org/text.asp?2015/33/4/585/167329



 ~ Introduction Top


Paecilomyces lilacinus is a filamentous fungus found in soil and air, which sometimes causes ocular infection. The majority of case reports involving P. lilacinus among healthy hosts are of endophthalmitis and keratitis.[1] The common predisposing factors are intra-ocular lens implantation, ocular trauma with or without a foreign body, ophthalmic surgery, and the wearing of contact lenses. It shows low susceptibility to conventional antifungals in vitro, and variable susceptibility to novel triazoles.[2] We report a rare case of keratomycosis by P. lilacinus, in an immunocompetent person following injury who responded well to treatment with ketoconazole. To the best of our knowledge, this is the first reported case of keratitis by P. lilacinus from the sub-Himalayan region.


 ~ Case Report Top


A 56-year-old male patient, mason by profession experienced a foreign body sensation in his right eye 2½ months back while working at a construction site. He developed redness, pain, watering and gradual diminution of vision. He consulted an ophthalmologist where he was treated with topical antibiotics and analgesics. There was no history of any ocular or systemic diseases. However, his eye condition remained unchanged, and he was referred to our Tertiary Care Institute.

The patient presented in the eye outpatient department (OPD) with pain and diminution of vision in the right eye. His visual acuity was limited to perception of light in the right eye and 6/6 in the left eye. Examination of the left eye was within normal limits. There was oedema of the right upper eyelid with deep ciliary congestion. On slit lamp examination, the right eye showed, 5.5 mm × 5 mm of epithelial defect in the centre of cornea with yellowish white stromal infiltrates involving 3/4 depth of the cornea. Descemetocele of the size 2 mm × 1 mm was formed on inferior part of the ulcer. Margins of ulcer showed feathery projections with oedema of the surrounding cornea. The anterior chamber was shallow with no hypopyon [Figure 1].
Figure 1: Slit lamp examination showing central corneal infiltrate with feathery margins surrounded by severely oedematous cornea

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Corneal scrapings were sent for microbiological examination. About 10% KOH wet mount from the corneal scrapings did not reveal any fungal structures. Gram stain of the smear showed the presence of few Gram-positive diplococci and occasional polymorphonuclear cells. The sample was inoculated on Sabouraud's dextrose agar with chloramphenicol and incubated at 25°C. The patient was started on fortified cefazolin (50 mg/ml) and fortified gentamicin (13 mg/ml) eye drops at the rate of one drop hourly along with analgesics keeping in possibility of a bacterial corneal ulcer. A soft bandage contact lens was also applied as there was an impending perforation of corneal ulcer. There was no improvement in the patient's symptoms on the above treatment after 1-week. Considering a greater possibility of fungal aetiology, a repeat corneal scraping sample was taken, but again the wet mount did not demonstrate any hyphae. The second sample was also cultured for fungal isolation.

There was floccose white growth in the first fungal culture tube after 1-week. The colonies were initially white, velvety and powdery which turned into lilac colour later [Figure 2]. Lactophenol cotton blue wet mount of the growth showed the presence of septate hyphae with long tapering phialides and globose conidia suggestive of P. lilacinus [Figure 3].
Figure 2: Culture showing lilac coloured colonies of Paecilomyces lilacinus on Sabouraud's dextrose agar

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Figure 3: Lactophenol cotton blue mount with of Paecilomyces lilacinus demonstrating long conidiophores arising from hyphae, tapering philiades and chains of conidia

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The patient was then started on treatment with topical natamycin 5% at a rate of one drop 5 times a day, oral ketoconazole (100 mg twice a day), 1% atropine drops 3 times a day along with anti-inflammatory drugs.

Similar type of fungal colonies was obtained in the second sample culture also. Thus, the isolation of the same fungus identified as P. lilacinus from two different corneal scrapings confirmed the diagnosis of fungal origin.

On follow-up, at 2 weeks, improvement was noticed in the form of decrease in the epithelial defect to 4 mm × 4 mm in size and appearance of a demarcation line surrounding the ulcer [Figure 4]. On second follow-up in the OPD at 6 weeks, there was complete healing of the ulcer, with epithelisation of the defect and formation of leucomatous opacity in the seroma of the cornea [Figure 5].
Figure 4: Photograph at 2 weeks follow-up showing decrease in the epithelial defect to 4 mm × 4 mm in size and appearance of a demarcation line surrounding the ulcer

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Figure 5: Photograph at 6 weeks, showing complete healing of the ulcer, with epithelisation of the defect and formation of leucomatous opacity in the siroma of the cornea

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 ~ Discussion Top


Paecilomyces lilacinus is a rare cause of filamentous keratitis. On extensive research of the literature, we could find only few studies that have reported Paecilomyces as a causative agent of keratomycosis. Studies from different parts of India have reported an isolation rate ranging from 0.46% to 5% of the total fungal pathogens from cases of keratomycosis.[3],[4],[5]

The treatment of P. lilacinus infections has been difficult due to resistance to commonly used antifungals.[6] The organism is resistant to natamycin, amphotericin B and 5 flurocytosine. It has variable sensitivity to imidazoles. Voriconazole, a triazole antifungal agent, is often administered to treat P. lilacinus infections. In our case, the patient was unable to bear the expensive treatment with voriconazole. He was thus started on ketoconazole, to which he responded well. Ketoconazole has poor in vitro activity against P. lilacinus with high minimum inhibitory concenteration. But response was good in our patient so maybe this drug can be tried in our set up where the socio-economic condition of the patients is not very good. Monden et al., retrospectively reviewed four cases of P. lilacinus keratitis and concluded that some patients may not require voriconazole treatment.[7]

Although Paecilomyces spp. are uncommon pathogens, they can produce serious infections in immunocompromised patients but the incidence of infections in immunocompetent hosts is also increasing.[8] The majority of published case reports involving P. lilacinus among healthy uncompromised host are of endophthalmitis that occurred following intra-ocular lens implantation.[9] In our case, there was no history suggestive of immunosuppression and any intra-ocular lens implantation.

In contrast to the other species belonging to the genus, P. lilacinus generally shows a poor response to conventional antifungal drugs. Therefore, correct identification of clinical isolates to the species level is mandatory for the appropriate treatment of the disease. We also suggest that corneal scrapings should be obtained and cultured as early as possible to ensure that appropriate antibiotic or antifungal treatments are initiated in a timely manner.

 
 ~ References Top

1.
Mahon CR. Textbook of Diagnostic Microbiologu. nd ed. Saunders Elsevier, Missouri, USA; 2000. p. 1101-2.  Back to cited text no. 1
    
2.
Pastor FJ, Guarro J. Clinical manifestations, treatment and outcome of Paecilomyces lilacinus infections. Clin Microbiol Infect 2006;12:948-60.  Back to cited text no. 2
    
3.
Rautaraya B, Sharma S, Kar S, Das S, Sahu SK. Diagnosis and treatment outcome of mycotic keratitis at a tertiary eye care center in eastern India. BMC Ophthalmol 2011;11:39.  Back to cited text no. 3
    
4.
Gill PK, Devi P. Keratomycosis-aretrospective study from North Indian tertiary care institute. J Indian Acad Clin Med 2011;12:271-3.  Back to cited text no. 4
    
5.
Sanjeev H, Karnaker VK, Vijay P, Pai AK, Rai R, Krishnaprasad MS. Fungal profile of infectious keratitis in a tertiary care hospital-our experience. NUJHS 2012;2:2.  Back to cited text no. 5
    
6.
Yuan X, Wilhelmus KR, Matoba AY, Alexandrakis G, Miller D, Huang AJ. Pathogenesis and outcome of Paecilomyces keratitis. Am J Ophthalmol 2009;147:691-6.e3.  Back to cited text no. 6
    
7.
Monden Y, Sugita M, Yamakawa R, Nishimura K. Clinical experience treating Paecilomyces lilacinus keratitis in four patients. Clin Ophthalmol 2012;6:949-53.  Back to cited text no. 7
    
8.
Carey J, D'Amico R, Sutton DA, Rinaldi MG. Paecilomyces lilacinus vaginitis in an immuno-competent patient. Emerg Infect Dis 2003;9:1155-8.  Back to cited text no. 8
    
9.
Ajello L, Hay RJ. Medical mycology. In Topley and Wilsons Medical Microbiology. 10th ed. Oxford University Press, NewYork, USA; 2005. p. 251, 282, 758.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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