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Aspergillus terreus Infection in a Sutureless Self-sealing Incision Made During Cataract Surgery

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Abstract

Here, we describe a case of keratitis caused by Aspergillus terreus in an 80-year-old immunocompetent woman 1 month after uneventful cataract surgery. The patient presented with decreased visual acuity (20/50) and severe pain in her right eye. Examination revealed a 3.5 × 4.5 mm white-colored deep stromal infiltration located on the temporal corneal tunnel incision. Corneal scraping samples were obtained for cytological and culture examinations. The cinnamon-brown colonies consisting of a dense felt of conidiophores were identified as A. terreus using molecular data. Using CLSI M38-A2 microdilution method, minimum inhibitory concentration values of amphotericin B, itraconazole, voriconazole, and posaconazole were determined to be 2, 1, 0.25, and 1 μg/ml, respectively, and minimum effective concentration values of caspofungin and anidulafungin were ≤0.03 and ≤0.03, respectively, at 48 h for the A. terreus strain. Antifungal therapy was started as topical 1 % voriconazole drops hourly and 5 % natamycin ointment five times a day; however, corneal infection and melting progressed despite the ongoing intensive treatment and visual acuity dropped to the 20/200 level at the end of the first week. Amniotic membrane transplantation was performed to promote corneal healing. Topical medication was tapered and discontinued within 2 months based on the clinical features. The ulcer healed with scarring and vascularization, and visual acuity improved to 20/50. In conclusion, A. terreus is a very uncommon cause of mycotic keratitis and is especially rare after cataract surgery. We suggest that early and accurate diagnosis and appropriate treatment of A. terreus keratitis may have a major impact on preventing severe disease complications.

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References

  1. Balajee SA. Aspergillus terreus complex. Med Mycol. 2009;47(suppl 1):s42–6.

    Article  PubMed  Google Scholar 

  2. Fungal Infections Aspergillus terreus. Leading International Fungal Education (LIFE). Retrieved, 13 October 2013.

  3. Fernández MS, Rojas FD, Cattana ME, et al. Aspergillus terreus complex: an emergent opportunistic agent of onychomycosis. Mycoses. 2013;56:477–81.

    Article  PubMed  Google Scholar 

  4. Singh SM, Sharma S, Chatterjee PK. Clinical and experimental mycotic keratitis caused by Aspergillus terreus and the effect of subconjunctival oxiconazole treatment in the animal model. Mycopathologia. 1990;112:127–37.

    Article  CAS  PubMed  Google Scholar 

  5. Garg P, Mahesh S, Bansal AK, Gopinathan U, Rao GN. Fungal infection of sutureless self-sealing incision for cataract surgery. Ophtalmology. 2003;110:2173–7.

    Article  Google Scholar 

  6. Chakrabarti A, Shivaprakash MR, Singh R, et al. Fungal endophtalmitis: fourteen years’ experience from a center in India. Retina. 2008;28:1400–7.

    Article  PubMed  Google Scholar 

  7. Moinfar N, Smiddy WE, Miller D, Miller D, Herschel K. Posttraumatic Aspergillus terreus endophtalmitis masquerading as dispersed lens fragments. J Cataract Refract Surg. 2007;33:739–40.

    Article  PubMed  Google Scholar 

  8. Verghese S, Palani R, Thirunavakarasu N, Chellamma T, Pathipata P. Peritonitis due to Aspergillus terreus in a patient undergoing continuous ambulatory peritoneal dialysis. Mycoses. 2008;51:174–6.

    Article  PubMed  Google Scholar 

  9. Baddley JW, Pappas PG, Smith AC, Moser SA. Epidemiology of Aspergillus terreus at a university hospital. J Clin Microbiol. 2003;41:5525–9.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Steinbach WJ, Benjamin DK Jr, Kontoyiannis DP, et al. Infections due to Aspergillus terreus: a multicenter retrospective analysis of 83 cases. Clin Infect Dis. 2004;39:192–8.

    Article  PubMed  Google Scholar 

  11. Sutton DA, Sanche SE, Revankar SG, Fothergill AW, Rinaldi MG. In vitro amphotericin B resistance in clinical isolates of Aspergilus terreus, with a head-to-head comparison to voriconazole. J Clin Microbiol. 1999;37:2343–5.

    CAS  PubMed Central  PubMed  Google Scholar 

  12. Lass-Flörl C, Alastruey-Izquierdo A, Cuenca-Estrella M, Perkhofer S, Rodriguez-Tudela JL. In vitro activities of various antifungal drugs against Aspergillus terreus: global assessment using the methodology of the European Committee on Antimicrobial Susceptibility Testing. Antimicrob Agents Chemother. 2009;53:794–5.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Thomas PA, Kaliamurthy J. Mycotic keratitis: epidemiology, diagnosis, and management. Clin Microbiol Infect. 2013;19:210–20.

    Article  CAS  PubMed  Google Scholar 

  14. Valenton M. Wound infection after cataract surgery. Jpn J Ophthalmol. 1996;40:447–55.

    CAS  PubMed  Google Scholar 

  15. Cosar CB, Cohen EJ, Rapuano CJ, Laibson PR. Clear corneal wound infection after phacoemulsification. Arch Ophthalmol. 2001;119:1755–9.

    Article  CAS  PubMed  Google Scholar 

  16. Heaven CJ, Davison CR, Cockcroft PM. Bacterial contamination of nylon corneal sutures. Eye. 1995;9:116–8.

    Article  PubMed  Google Scholar 

  17. Mendicute J, Orbegozo J, Ruiz M, et al. Keratomycosis after cataract surgery. J Cataract Refract Surg. 2000;26:1660–6.

    Article  CAS  PubMed  Google Scholar 

  18. Jain V, Borse N, Shome D, Natarajan S. Recalcitrant fungal tunnel infection treated with intrastromal injection of voriconazole. Int Ophthalmol. 2010;30:723–5.

    Article  PubMed  Google Scholar 

  19. Thomas PA. Current perspectives on ophthalmic mycoses. Clin Microbiol Rev. 2003;16:730–97.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  20. Turin L, Riva F, Galbiati G, Cainelli T. Fast, simple and highly sensitive double-rounded polymerase chain reaction assay to detect medically relevant fungi in dermatological specimens. Eur J Clin Invest. 2000;30:511–8.

    Article  CAS  PubMed  Google Scholar 

  21. Hall TA. BioEdit: a user-friendly biological sequence alignment editor and analysis program for Windows 95/98/NT. Nucl Acids Symp Ser. 1999;41:95–8.

    CAS  Google Scholar 

  22. CLSI. Reference method for broth dilution antifungal susceptibility testing of filamentous fungi: Approved Standard-Second Edition. CLSI document M38-A2. Wayne, PA. Clinical and Laboratory Standards Institute; 2008.

  23. Espinel-Ingroff A, Cuenca-Estrella M, Fothergill A, et al. Wild-type MIC distributions and epidemiological cut-off values for amphotericin B and Aspergillus spp. for the CLSI broth microdilution method (M38-A2 document). Antimicrob Agents Chemother. 2011;55:5150–4.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  24. Espinel-Ingroff A, Diekema DJ, Fothergill A, et al. Wild-type MIC distributions and epidemiological cut-off values for the triazoles and six Aspergillus spp. for the CLSI broth microdilution method (M38-A2 document). J Clin Microbiol. 2010;48:3251–7.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  25. Pfaller MA, Boyken L, Hollis RJ, et al. Wild-type minimum effective concentration distributions and epidemiologic cut-off values for caspofungin and Aspergillus spp. as determined by Clinical and Laboratory Standards Institute broth microdilution methods. Diagn Microbiol Infect Dis. 2010;67:56–60.

    Article  CAS  PubMed  Google Scholar 

  26. Alastruey-Izquierdo A, Mellado E, Peláez T, et al. FILPOP Study Group. Population-based survey of filamentous fungi and antifungal resistance in Spain (FILPOPStudy). Antimicrob Agents Chemother. 2013;57:3380–7.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  27. Singer JA. Frown incision for minimizing induced astigmatism after small incision cataract surgery with rigid optic intraocular lens implantation. J Cataract Refract Surg. 1991;17:677–88.

    Article  PubMed  Google Scholar 

  28. Xie L, Zhai H, Shi W, et al. Hyphal growth patterns and recurrence of fungal keratitis after lamellar keratoplasty. Ophtalmology. 2008;115:983–7.

    Article  Google Scholar 

  29. Deak E, Wilson SD, White E, Carr JH, Balajee SA. Aspergillus terreus accessory conidia are unique in surface architecture, cell wall composition and germination kinetics. PLoS ONE. 2009;4:e7673.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Hariprasad SM, Mieler WF, Lin TK, Sponsel WE, Graybill JR. Voriconazole in the treatment of fungal eye infections: a review of current literature. Br J Ophthalmol. 2008;92:871–8.

    Article  CAS  PubMed  Google Scholar 

  31. Jhanji V, Sharma N, Mannan R, Titiyal JS, Vajpayee RB. Management of tunnel fungal infection with voriconazole. J Cataract Refract Surg. 2007;33:915–7.

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

SAA does not have any conflict of interest related to this manuscript. Otherwise, she has received research Grants from Pfizer and lecture honoraria from Merck, Pfizer, and Gilead. The other authors declare that no competing interests exist.

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Authors and Affiliations

  1. Department of Ophthalmology, Faculty of Medicine, University of Çukurova, Adana, Turkey

    Elif Erdem, Ebru Esen & Meltem Yağmur

  2. Division of Mycology, Department of Microbiology, Faculty of Medicine, University of Çukurova, Adana, 01330, Turkey

    Hazal Kandemir & Macit İlkit

  3. Department of Medical Microbiology, Faculty of Medicine, University of Hacettepe, Ankara, Turkey

    Sevtap Arıkan-Akdağlı

  4. Department of Pathology, Faculty of Medicine, University of Çukurova, Adana, Turkey

    Arbil Açıkalın

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  1. Elif Erdem
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Correspondence to Macit İlkit.

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Erdem, E., Kandemir, H., Arıkan-Akdağlı, S. et al. Aspergillus terreus Infection in a Sutureless Self-sealing Incision Made During Cataract Surgery. Mycopathologia 179, 129–134 (2015). https://doi.org/10.1007/s11046-014-9829-2

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  • DOI: https://doi.org/10.1007/s11046-014-9829-2

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