alexa Successful Treatment of Paecilomyces lilacinus Keratitis and Endophthalmitis with Penetrating Keratoplasty, Pars Plana Vitrectomy, Intravitreal and Oral Voriconazole | Open Access Journals
ISSN: 2155-9570
Journal of Clinical & Experimental Ophthalmology
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Successful Treatment of Paecilomyces lilacinus Keratitis and Endophthalmitis with Penetrating Keratoplasty, Pars Plana Vitrectomy, Intravitreal and Oral Voriconazole

Robert Glazier1, Scott Oliver1, Marilyn Levi2 and Christopher Gelston1*
1Department of Ophthalmology, Rocky Mountain Lions Eye Institute, University of Colorado School of Medicine, Aurora, CO, USA
2Department of Infectious Disease, University of Colorado School of Medicine, Aurora, CO, USA
Corresponding Author : Christopher Gelston, M.D
Rocky Mountain Lions Eye Institute
University of Colorado
1675 Aurora Ct., Aurora
CO 80045, USA
Tel: (720) 848-2500
Fax: (720) 848-5014
E-mail: [email protected]
Received October 16, 2012; Accepted November 06, 2012; Published November 12, 2012
Citation: Glazier R, Oliver S, Levi M, Gelston C (2012) Successful Treatment of Paecilomyces lilacinus Keratitis and Endophthalmitis with Penetrating Keratoplasty, Pars Plana Vitrectomy, Intravitreal and Oral Voriconazole. J Clin Exp Ophthalmol 3:253. doi:10.4172/2155-9570.1000253
Copyright: © 2012 Glazier R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

Paecilomyces lilacinus is a rarely identified cause of local and systemic infections. Of reported P. lilacinus infection cases in the literature there is a preponderance of oculomycoses composing 51.3% of reported cases in a recent review often associated with intraocular surgery or trauma with or without a foreign body.

Keywords
Paecilomyces lilacinus; Keratitis; Voriconazole
Paecilomyces lilacinus is a rarely identified cause of local and systemic infections. Of reported P. lilacinus infection cases in the literature there is a preponderance of oculomycoses composing 51.3% of reported cases in a recent review often associated with intraocular surgery or trauma with or without a foreign body [1]. Historically, treatment of P. lilacinus infections has been difficult due to resistance to commonly used antifungals [2]. With the advent of newer antifungal agents such as voriconazole there is a growing body of case reports of successful management of these infections. Here we report an uncommon case of P. lilacinus keratitis with endophthalmitis in the setting of a penetrating keratoplasty treated successfully with intravitreal and systemic voriconazole.
A healthy 58-year-old pseudophakic female, with a history of soft contact lens use, was referred to our tertiary care facility one month after undergoing a penetrating keratoplasty for a non-healing bacterial corneal ulcer. Initial bacterial and fungal cultures prior to surgery only showed Streptococcus species; however pathology of the corneal button showed fungal elements within the corneal stroma. Three weeks postoperatively she developed a recurrent ulcer within the graft and was referred to our facility for further management of a possible undetected fungal infection that subsequently affected the corneal graft.
On initial presentation the patient’s vision was hand motion at 3 feet. She had 2+ anterior chamber cells and flare, a corneal epithelial defect with an underlying 2.7 x 3.8 mm infiltrate within the corneal graft (Figure 1). The corneal infiltrate was re-cultured and the patient was started on hourly-fortified topical vancomycin (25 mg/mL), tobramycin (14 mg/mL), and topical Natamycin (5%) eye drops. Oral ketoconazole 200 mg twice daily was as also added.
Two days after presentation the corneal infiltrate had increased in size with progression to the graft-host margin. The anterior chamber inflammation had increased to 4+ cells and flare and an ocular ultrasound demonstrated vitritis (Figure 2). The patient emergently underwent a repeat penetrating keratoplasty and anterior chamber wash out. Intra-operatively, the intraocular lens expulsed from the eye and explanted. Intravitreal injections of vancomycin (1 mg/0.1 mL), ceftazidime (2.2 mg/0.1 mL), and voriconazole (0.1 mg/0.1 mL) were administered at the conclusion of the case. Vitreous samples were sent for culture and the corneal button was sent for pathologic analysis. Post-operatively the patient was started on topical prednisolone acetate 1% four times daily, moxifloxacin every two hours andoral ketoconazole 200 mg twice daily. On post-operative day two, there was persistent anterior chamber and vitreous inflammation. Repeat ocular ultrasound demonstrated subhyaloid and intravitreal infiltrates. The preliminary analysis from the recent operative cultures demonstrated fungal elements with mold forms. Intravitreal voriconazole was reinjected. On post-operative day three, a 25-gauge pars plana vitrectomy was performed and intravitreal voriconazole was again injected.
Four days after the repeat penetrating keratoplasty and vitrectomy the initial vitreous cultures were identified as Paecilomyces lilacinus. Pathologic evaluation of the corneal button revealed full thickness inflammation, fungal elements in the anterior two thirds of cornea with endothelial cell loss. Infectious disease consultation was made and the patient was initiated on oral voriconazole 400 mg twice daily.
Over the subsequent two weeks the anterior chamber and vitreous inflammation persisted but showed gradual improvement. Blood voriconazole levels were drawn and shown to be within systemic therapeutic range (3.54 mcG/mL). After three weeks of oral voriconazole therapy the patient’s best-corrected vision improved to 20/300 with rare anterior chamber and vitreous cells. After one month of high dose voriconazole therapy the dosage was decreased to 200 mg twice daily for an additional three months. Over which time there was no sign of recurrent keratitis, the anterior chamber and vitreous inflammation resolved and the patient’s best-corrected vision improved to 20/60.
Paecilomyces lilacinus is a rare cause of keratitis and endophthalmitis. Treatment has been variably successful owing in part to the high degree of resistance of Paecilomyces organisms. Amphotericin B, itraconazole and ketoconazole have poor in vitro activity against P. lilacinus with high mean inhibitory concentrations [3].
The advent of new triazole antifungals particularly voriconazole has been shown to have lower mean inhibitory concentrations and to be an effective treatment of Paecilomyces oculomycoses [4]. This is in part that orally administered voriconazole has good bioavailability and achieves therapeutic aqueous and vitreous levels [5]. Prompt recognition of this infection combined with long term oral voriconazole treatment can be effective in treating Paecilomyces oculomycoses.
Disclosure
This paper has not previously been presented at any meetings or published. The authors had no financial support or have any propriety interest in the paper.
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