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Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 63-64

A case report of fungal keratitis due to Fusarium oxysporum after an injury by fingernails

Department of Ophthalmology, Dr. Vaishampayan Memorial Government Medical College, Solapur, Maharashtra, India

Date of Submission27-Mar-2022
Date of Acceptance16-Aug-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Hemali P Kanabar
Building B/52, Flat 302, Sector 1, Shantinagar, Mira Road East, Dist – Thane - 401 107, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_771_22

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Fusarium keratomycosis is a disastrous fungal infection of the eye, can affect healthy individuals, is cumbersome to treat, and has a poor prognosis. Herein, we present a case of a healthy 40-year-old female patient, who presented with chief complaints of pain, redness, and watering of the left eye since 15 days along with the diminution of vision. She had a history of trauma to the left eye by fingernails, followed by the development of symptoms. KOH wet preparation of corneal scrapings revealed fungal elements with the growth of culture on Sabouraud's dextrose agar confirming the etiological agent as Fusarium oxysporum. This case is reported for its rarity.

Keywords: Corneal ulcer, fungal keratitis, Fusarium oxysporum

How to cite this article:
Sarawade SS, Kanabar HP, Jadhav SS. A case report of fungal keratitis due to Fusarium oxysporum after an injury by fingernails. Indian J Ophthalmol Case Rep 2023;3:63-4

How to cite this URL:
Sarawade SS, Kanabar HP, Jadhav SS. A case report of fungal keratitis due to Fusarium oxysporum after an injury by fingernails. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:63-4. Available from: https://www.ijoreports.in/text.asp?2023/3/1/63/368221

Keratomycoses are rare and can be underestimated. They represent one of the most severe forms of corneal infections. They are an invasive fungal infection of the corneal stroma with corneal epithelium being the main portal of entry. It is considered an infrequent condition, although it is more common in tropical and subtropical areas of developing countries, where the main risk factors are defects in the corneal epithelium caused by trauma, which often involves vegetative matter.[1] Currently, the most common fungi involved in these infections are several species of the genus Fusarium, the most common being Fusarium solani, which is the most virulent,[2] resistant to many antifungals.[1]

The first case of isolated Fusarium oxysporum keratomycosis was reported in India from Bangalore in the year 2001.[2] Another case of bilateral Fusarium oxysporum keratitis after laser in situ keratomileusis was reported in 2012.[3] Not many cases with isolated Fusarium oxysporum sps have been reported, most likely due to it being underdiagnosed and also due to its difficult recovery on culture.

  Case Report Top

A 40-year-old healthy homemaker presented with chief complaints of pain, redness, watering, and diminution of vision in her left eye since 15 days. She had sustained a fingernail trauma 15 days back. She also gave a history of seeking treatment 7 days back from some local doctor who had administered her local antibiotic eyedrops which did not relieve her symptoms. On local examination, the patient had significant periorbital edema, more so in the left upper eyelid with discharge from the same eye. On slit-lamp examination, the cornea stained positive with 2% fluorescein dye, showing a central corneal ulcer of approximately 5 mm × 4 mm in size, irregular in shape, with a whitish cottony appearance with feathery margins. The anterior chamber had a hypopyon of height 3 mm and appeared thick in consistency [Figure 1]a. The vision was impaired in the left eye to only perception of light and projection of rays. Her intraocular tension was raised in the affected eye on digital assessment. The patency of the sac was confirmed with sac syringing. The right eye was completely normal.
Figure 1: (a) First day of presentation: Stain positive corneal ulcer size 5 × 4 mm with hypopyon of height 3 mm. (b) Post-treatment on day 21 – corneal ulcer size 3 × 3 mm with reduction in stromal infiltration and hypopyon height reduced to 1 mm. (c) Sickle-shaped macroconidia in clusters on the LCB mount. (d) Highly septate, hyaline, and fungal hyphae on the KOH mount. (e) Growth of Fusarium colony on the SDA plate

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She was administered oral antibiotic ciprofloxacin 500 mg twice a day, local antibiotic moxifloxacin (0.5%) eyedrops, and oral ascorbic acid 500 mg, along with a cycloplegic eye ointment – atropine sulfate 1%. Considering the suspicion of keratomycosis, systemic antifungal – oral fluconazole 150 mg twice a day – was administered along with local natamycin 5% eye drops twice a day. KOH wet preparation revealed the presence of septate, branched, hyaline hyphae, indicative of infection due to a filamentous fungus [Figure 1]d. No bacterial growth was observed on blood agar within 24 hours. Culture on Sabouraud's dextrose agar (SDA) grew white, cottony colonies [Figure 1]e. Lactophenol cotton blue (LCB) mount showed sickle-shaped macroconidia in clusters [Figure 1]c The fungus was identified as Fusarium oxysporum after which the adjuvant antifungal agent voriconazole (1%) eyedrop was added to her treatment. After 21 days of treatment, it was evident that the corneal ulcer was reduced in size to just 3 mm × 3 mm with the hypopyon height reducing to 1 mm, and visual acuity improved to finger counting at 2 m [Figure 1]b.

  Discussion Top

Filamentous fungi are responsible for up to one-third of all cases of keratitis in certain parts of the world. Aspergillus and Fusarium are responsible for one-third of all traumatic keratitis.[4]

Filamentous fungal keratitis usually occurs in healthy young males engaged in agricultural or other outdoor work; these fungi do not penetrate an intact epithelium, and invasion is secondary to trauma.[1]

Due to the large rural population and environmental factors, keratomycosis is common in India, especially in the southern and western parts of India due to high temperature and humidity.[5] Injury to the cornea is the leading cause of microbial keratitis, particularly fungal keratitis.

Fusarium species have also been reported from patients suffering from endophthalmitis, otitis media, onychomycoses,[6] stasis ulcers, breast abscess mycetoma,[7] sinusitis, pulmonary infections, endocarditis, peritonitis, central venous catheter infections, septic arthritis, and fungemia. Fusarium oxysporum has been described as a ubiquitous organism, its incidence has been increasing in immunocompetent people, and disseminated infection can occur in immunosuppressed individuals. A rare case of Fusarium oxysporum being acquired in utero was also reported.[8] In our case, the patient gave a history of fingernail injury, which could be the reason for the transfer of the etiological agent from her fingernail to the cornea.

Laboratory diagnosis is crucial in the management of mycotic keratitis. Direct demonstration of the fungus in the smear leads to an immediate diagnosis. In most of the private practitioners and smaller centers where culture facilities are not available, KOH smear is the only reliable and easy-to-use diagnostic tool, and it works in 90–95% of the cases.[9] The true hyphal fragments can usually be recognized under low power and confirmed by higher magnification. In our case, highly septate, branched, and hyaline hyphae were found abundantly on KOH mount.

Hypopyon is common in patients with severe fungal keratitis and can cause ocular hypertension. In our case, the patient had a thick, non-mobile hypopyon of height 3 mm on presentation along with raised intraocular pressure.

  Conclusion Top

The advent of antibiotics and steroids has been blamed for the increasing incidence of fungal keratitis. In our case, the patient was not suspected to have fungal keratitis when she first presented to a local clinician who prescribed only antibiotic eyedrops to the patient which did not improve her condition. We started her on empirical treatment with antibiotics and antifungals, and after confirming the fungal etiology, the adjuvant antifungal agent was added to her treatment which resulted in significant improvement in the patient's signs and symptoms along with visual acuity.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Thomas PA, Kaliamurthy J. Mycotic keratitis: Epidemiology, diagnosis and management. Clin Microbiol Infect 2013;19:210-20.  Back to cited text no. 1
Vijaya D, Sumathi, Malini. Keratomycosis due to Fusarium oxysporum--a case report. Indian J Pathol Microbiol 2001;44:337-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
Labiris G, Troeber L, Gatzioufas Z, Stavridis E, Seitz B. Bilateral Fusarium oxysporum keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2012;38:2040-4.  Back to cited text no. 3
Liesegang TJ, Forster RK. Spectrum of microbial keratitis in South Florida. Am J Ophthalmol 1980;90:38-47.  Back to cited text no. 4
Fungal Keratitis-Asia Pacific. American Academy of Ophthalmology. Published October 10, 2016. Available from: https://www.aao.org/topic-detail/fungal-keratitis-asia-pacific. [Last accessed on 2022 Mar 22].  Back to cited text no. 5
Veiga FF, de Castro-Hoshino LV, Sato F, Bombassaro A, Vicente VA, Mendes V, et al. Fusarium oxysporum is an onychomycosis etiopathogenic agent. Future Microbiol 2018;13:1745-56.  Back to cited text no. 6
Anandi V, Vishwanathan P, Sasikala S, Rangarajan M, Subramaniyan C, Chidambaram N. Fusarium solani breast abscess. Indian J Med Microbiol 2005;23:198-9.  Back to cited text no. 7
[PUBMED]  [Full text]  
Carvalho VO, Vicente VA, Werner B, Gomes RR, Fornari G, Herkert PF et al. Onychomycosis by Fusarium oxysporum probably acquired in utero. Med Mycol Case Rep 2014;6:58-61.  Back to cited text no. 8
Agarwal A, Agarwal R. Role of potassium hydroxide preparation in the management of mycotic corneal ulcers. Indian J Ophthalmol 2012;60:336. doi: 10.4103/0301-4738.98732.  Back to cited text no. 9
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