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PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 43

Caspofungin: Saviour in a case of recalcitrant fungal keratitis


1 Chandigarh Cornea Clinic, BVP Medical Center, Sector 24, Chandigarh, India
2 Department of Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission03-Jan-2020
Date of Acceptance12-Aug-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Sujata Dwivedi
Bharat Vikas Parishad Chartitable Centre, Inside Indira Holiday Home, Sector 24, Chandigarh - 160 023
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_13_20

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  Abstract 


Keywords: Caspofungin, fungal keratitis, intracamaral, topical


How to cite this article:
Dwivedi S, Rudramurthy SM. Caspofungin: Saviour in a case of recalcitrant fungal keratitis. Indian J Ophthalmol Case Rep 2021;1:43

How to cite this URL:
Dwivedi S, Rudramurthy SM. Caspofungin: Saviour in a case of recalcitrant fungal keratitis. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Feb 26];1:43. Available from: https://www.ijoreports.in/text.asp?2021/1/1/43/305482



A 65-year-old male presented with pain and diminished vision in the left eye for 6 weeks. There was no history of trauma. He was diagnosed as fungal keratitis based on positive KOH smear 5 weeks ago and treated with hourly Natamycin. On worsening, Voriconazole eye drops were added after 2 weeks. He was referred because of worsening. He had hand motions vision, high IOP digitally, central corneal epithelial defect of 4 mm × 4.5 mm around a plaque-like infiltrate of 2 mm × 1.5 mm with satellite lesions at edges of the epithelial defect, and 4.5 mm hypopyon [Figure 1]a.
Figure 1: (a) Clinical picture at initial presentation, (b) after two injections of intracameral voriconazole, (c) increase in infiltrate after subsequent two injections of amphotericin, (d) reduced anterior chamber exudates 8 days after initiating caspofungin

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Scrapings revealed septate hyphae on the KOH mount. In view of nonresponding infiltrate with increasing hypopyon and secondary glaucoma, anterior chamber wash with intracameral voriconazole injection 100 μg/0.1 mL was given. Medical management continued with Natamycin, voriconazole, and amphotericin 0.15% hourly dose along with oral voriconazole 200 mg and acetazolamide twice a day. After two days, infiltrate was static, and hypopyon decreased to 3 mm. Repeat intracameral voriconazole was given, but two days later, there was an increase in hypopyon. Because of non-response, voriconazole injection was deferred, and intracameral amphotericin B 5 μg/0.1 mL was injected twice at a gap of 3 days with no response [Figure 1]b and [Figure 1]c.

We considered Caspofungin at this juncture as it has worked in some cases of refractory fungal keratitis.[1],[s2],[3] Intracameral caspofungin 50 μg/0.1 mL was injected, and topical caspofungin 0.5% eye drops were started in one hourly dose. The rest of the antifungals were stopped. After 1 week, anterior chamber exudates began organizing [Figure 1]d.

Fungal culture grew hyaline mold, identified as Acrophialophora fusispora. Antifungal susceptibility testing revealed low MIC90 of 0.03 mg/L to voriconazole and high MIC90 to caspofungin (8 mg/L). Contrary to this report, clinical response was evident after 1 week of caspofungin therapy. Hypopyon disappeared in 3 weeks, and infiltrate resolved in another 3 weeks.


  Discussion Top


Caspofungin has been used very sparingly in the management of refractory fungal keratitis. It can used as intracameral injection and/or topical therapy..[4] We need to use this drug more often to explore its potential.[5]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



 
  References Top

1.
Tu EY. Alternaria keratitis: Clinical presentation and resolution with topical fluconazole or intrastromal voriconazole and topical caspofungin. Cornea 2009;28:116-9.  Back to cited text no. 1
    
2.
Hurtado-Sarrió M, Duch-Samper A, Cisneros-Lanuza A, Diaz-Llopis M, Peman-Garcia J, Vazquez-Polo A. Successful topical application of caspofungin in the treatment of fungal keratitis refractory to voriconazole. Arch Ophthalmol 2010;128:941-2.  Back to cited text no. 2
    
3.
Neoh CF, Leung L, Vajpayee RB, Stewart K, Kong DC. Treatment of Alternaria keratitis with intrastromal and topical caspofungin in combination with intrastromal, topical, and oral voriconazole. Ann Pharmacother 2011;45:e24.  Back to cited text no. 3
    
4.
Neoh CF, Daniell M, Chen SC-A, Stewart K, Kong DCM. Clinical utility of caspofungin eye drops in fungal keratitis. Int J Antimicrob Agents 2014;44:96-104.  Back to cited text no. 4
    
5.
Neoh CF, Jacob J, Leung L, Li J, Stathopoulos A, Stewart K, et al. Stability of extemporaneously prepared 0.5-percent caspofungin eye drops: A potential cost-savings exercise. Antimicrob Agents Chemother 2012;56:3435-7.  Back to cited text no. 5
    


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