Fungal corneal ulcer in a 27 weeks primigravida with anemia and multi-vitamin deficiency

Siddharth Madan; Sarita Beri; Sarah Khan; Pragya Prakash; Rajesh Jain

doi:10.4103/ijo.IJO_957_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 2 | Page : 382-384

Fungal corneal ulcer in a 27 weeks primigravida with anemia and multi-vitamin deficiency

Siddharth Madan, Sarita Beri, Sarah Khan, Pragya Prakash, Rajesh Jain
Department of Ophthalmology, Lady Hardinge Medical College and Associated Hospitals, University of Delhi, New Delhi, India

Date of Submission	22-Apr-2021
Date of Acceptance	19-Oct-2021
Date of Web Publication	13-Apr-2022

Correspondence Address:
Siddharth Madan
Department of Ophthalmology, University College of Medical Sciences and Associated GTB Hospital, University of Delhi - 110 021, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_957_21

Abstract

Fungal keratitis is an infection of the cornea which can lead to severe visual compromise if not diagnosed on time and managed appropriately. It may present with minimal symptoms and many signs. Likely to be overlooked by the patient, it results in a late presentation when substantial damage has already occurred. It is usually seen in patients with a severe immune compromise such as acquired immunodeficiency syndrome (AIDS), uncontrolled diabetes, transplant patients on immune-suppressants or long-term steroids, and in pre-existing ocular surface disorder. This is a case report of a 27-week primigravida who presented with extreme fatigue and a fungal corneal ulcer with no preceding history of trauma or any other immune compromised state.

Keywords: Corneal ulcer and vitamin deficiency, fungal corneal ulcer, pregnancy and candida keratitis, vitamin A deficiency and eye

How to cite this article:
Madan S, Beri S, Khan S, Prakash P, Jain R. Fungal corneal ulcer in a 27 weeks primigravida with anemia and multi-vitamin deficiency. Indian J Ophthalmol Case Rep 2022;2:382-4

How to cite this URL:
Madan S, Beri S, Khan S, Prakash P, Jain R. Fungal corneal ulcer in a 27 weeks primigravida with anemia and multi-vitamin deficiency. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 27];2:382-4. Available from: https://www.ijoreports.in/text.asp?2022/2/2/382/343003

Fungal keratitis may develop in an otherwise healthy individual after trauma to the cornea with a vegetable matter or an organic foreign body. It is important to diagnose the condition early and manage it promptly lest it results in devastating complications. A proper history, examination, and treatment of associated morbidities are important for a successful outcome.

Case Report

A 31-year-old 27-week primigravida, presented with redness, gradually increasing whitish opacity over the cornea, and diminution of vision in the left eye for 2 months. This was associated with extreme fatigability for the same duration which gradually progressed to such an extent that she became physically handicapped and required wheelchair assistance for mobility. For the past 1 month, she also noticed generalized skin rashes [Figure 1]a and the development of pustules on her leg. There was no history of previous trauma, diabetes, or HIV. The best-corrected visual acuity (BCVA) was 6/6 oculus dextrus (OD) and 6/18 oculus sinister (OS). A slit-lamp examination revealed organized exudates like a cotton ball involving two-thirds of the corneal thickness with surrounding stromal edema [Figure 2]a. The intraocular pressures (IOP) were normal on a non-contact tonometer. The corneal scrapings sent for potassium hydroxide (KOH) and culture revealed candida species [Figure 2]b. A dermatological consultation for her rashes and pustules suggested contact dermatitis [Figure 1]a, [Figure 1]c and [Figure 1]d, an incidentally noted oral thrush [Figure 1]b with pyoderma of the leg [Figure 1]e. Suspecting a severe immunocompromise, an immunology expert opinion was sought. Investigations like the anti-nuclear antibody, anti-neutrophilic cytoplasmic antibody, C- reactive protein, rheumatoid arthritis factor, serum cryoglobulins, Immunoglobulin G (IgG), Immunoglobulin M (IgM), Immunoglobulin A (IgA), thyroid-stimulating hormone, HIV, Hepatitis B surface antigen (HBsAg), venereal disease research laboratory, chest X-ray, Ultrasound (USG) abdomen, anti-phospholipid antibody, anti-ds deoxyribonucleic acid (DNA), fasting blood sugar, and serum retinol (> 0.7 μmol/L) levels were within normal limits but the patient was found to be deficient in vitamin D3, B12, iron, and folic acid. This led to the diagnosis of anemia with pancytopenia along with multivitamin deficiency with fungal corneal ulcer, oral thrush, and pyoderma. Intrauterine growth retardation was confirmed on clinical examination and sonography. She was started on injectable iron sucrose, multivitamin supplements, and a high protein diet.

Figure 1: (a-d) Sequential patient photographs. The patient developed rashes over the face (a) and digits of her hands (c and d) suggestive of contact dermatitis, an incidentally noted oral thrush (b) with pyoderma of the leg (e)

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Figure 2: (a-d) Sequential photographs of corneal ulcer in various stages of healing with the microscopic appearance of the fungus. The slit-lamp examination revealed a corneal ulcer with surrounding stromal edema and ciliary congestion (a). The corneal scrapings revealed budding yeast cells on gram stain (b). After 6 weeks, the ulcer began to heal (c) with scarring (d)

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Hourly instillation of topical antifungals including natamycin 5% and itraconazole 1%, homatropine 2% three times a day, carboxy methylcellulose 0.5% four times a day, timolol 0.5% twice a day (BD) along with oral fluconazole 200 mg BD was initiated after a medical and obstetric consultation. She was also administered vitamin A supplementation (10,000 IU daily for nearly 6 weeks till delivery) as a conventional cut-off limit for serum retinol levels may underestimate the status of vitamin A in the last trimester of the pregnancy and in populations with a high prevalence of infections.^[1],[2] The patient was followed up daily. After 6 weeks, her condition improved and the ulcer healed with scarring with a BCVA of 6/12 OS [Figure 2]c and [Figure 2]d. Her topical antifungals were gradually tapered. Systemic administration of multivitamin supplements led to physical improvement in the patient and she could walk without support. Due to considerable corneal thinning [Figure 2]a, the patient was advised pressure patching of the left eye to prevent any inadvertent perforation due to the rise of intraocular pressure during vaginal delivery. However, the patient had to undergo a cesarean section due to obstetrical indications and delivered an underweight developmentally normal child with an uneventful postoperative ophthalmic outcome.

Discussion

A fungal corneal ulcer is a potentially sight-threatening infection of the cornea associated with significant morbidity, especially in warmer climates of developing countries. Various pathogenic fungi lead to keratitis including yeasts like the Candida species. Corneal scrapings are examined under the microscope for quick detection of fungal elements using a 10% KOH wet mount preparation and gram stain. They are cultured on blood agar, chocolate agar, Sabouraud's dextrose agar to identify the species and sensitivity.

While initiating any topical or systemic medication in pregnancy, its safety profile has to be kept in mind and appropriate obstetric advice sought when required. Natamycin and azoles are class C drugs except for oral fluconazole which was changed to category D in 2011 for all indications except a single dose at 150 mg to treat vaginal candidiasis. This change was made after several reports were published in which women taking chronic high doses (400–800 mg) of fluconazole in the first trimester gave birth to children with distinct congenital anomalies.^[3] Therefore, it is contraindicated in the first trimester of pregnancy, but can be given in the late second and third trimesters with obstetric consultation. An immunosuppressed state is one of the few indications for initiating oral antifungals. The systemic absorption of topical drugs is minimal since the 7 mL tear film is not able to sustain much of the 50 mL eye drop and a majority gets washed off. Hence, topical antifungals can be given preferably accompanied by punctal occlusion.

In case medical therapy fails, a penetrating keratoplasty may be performed as reported at the seventh month of pregnancy in an Asian female with spontaneous corneal melting which began at 5 months of gestation.^[4] There is not enough evidence to indicate the preferred timing of surgical intervention if required in a pregnant patient. Another aspect to keep in mind is the biochemical changes in the cornea during pregnancy due to estrogen and relaxin hormones which increase matrix metalloproteinases causing prostaglandin release^[5] and exacerbating corneal thinning and ectasia. This thinning of the cornea in a healing ulcer may be a risk factor for perforation due to an acute rise in the IOP during labor. But there have not been enough studies suggesting a role of a change in the mode of delivery in corneal ectasias or thinning, or any evidence showing an acute rise in IOP during labor sufficient to threaten the corneal integrity in compromised corneas.

Conclusion

It is important to keep in mind that the immunocompromised state in pregnancy can be worsened by multivitamin and mineral deficiencies leading to increased risk of opportunistic infections such as fungal corneal ulcers, delayed healing, and even physical dependence. Early diagnosis and treatment with multidisciplinary consultation are needed for a speedy recovery in these patients.

Declaration of patient consent

Informed consent was taken from the patient for inclusion of clinical photographs in the case report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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