Date Published: July 11, 2017
Author(s): Emmanuel O. Irek, Temitope O. Obadare, Patrick A. Udonwa, Olajumoke Laoye, Oyekola V. Abiri, Adenike O. Adeoye, Aaron O. Aboderin.
We report a rare cause of keratitis, due to Cylindrocarpon lichenicola, in a farmer with keratomycosis. Despite the acknowledged virulence of this fungus, a suitable antifungal for its management was not accessible.
A 67-year-old farmer presented with a two-week history of pain, mucopurulent discharge, redness and a corneal ulcer with a visual acuity of hand movement in the right eye. With a working diagnosis of infective keratitis, corneal scrapings were taken under a slit lamp biomicroscope for microbiological testing. Direct lactophenol cotton blue mounts revealed septate fungal hyphae, while fungal culture on Sabouraud dextrose agar at room temperature grew woolly mould phenotypically consistent with C. lichenicola.
The patient was started on hourly topical natamycin (5%), ciprofloxacin (0.3%), two-hourly instillation of tobramycin (0.3%) and atropine (1%) twice daily for three months following the isolation of the fungus. The eye healed with a corneal scar and no improvements in visual acuity.
This infection was difficult to manage due to the inaccessibility of a suitable antifungal, namely, voriconazole in our setting. Hence, there is a need for prompt identification and early institution of suitable antifungals in any patient with suspected keratomycosis.
Filamentous fungi are an emerging cause of keratitis worldwide,1 including occurrences of some rarer fungi. Only a few cases of keratitis due to Cylindrocarpon lichenicola have been reported in published literature in the world, none of these in sub-Saharan Africa. The occurrence of keratomycosis is, however, partly associated with farming,2 which is a predominant occupation in the tropics. Hence, keratomycosis from plant or soil particles laden with fungal materials is not uncommon in these areas.3C. lichenicola is a hyaline filamentous fungus which is also called Fusarium lichenicola and has been reclassified as a member of the Fusarium solani species complex.1 However, it rarely causes keratitis,4 although it has been implicated in cutaneous mycosis in immunocompetent patients.5,6 It has devastating effects on the eye following infection, despite use of suitable antifungals.3 In this article, we describe fungal keratitis caused by C. lichenicola in a man living in a semi-urban region in Nigeria.
A 67-year-old male farmer presented to the Ophthalmology Unit of Obafemi Awolowo University Teaching Hospitals Complex in Ile-Ife, Nigeria, with a two-week history of pain, mucopurulent discharge and redness in the right eye. There was no history of foreign body entry into the right eye, nor was there ocular trauma or instillation of traditional eye medication. The patient had earlier used chloramphenicol eye drops which he obtained over the counter. His fasting blood sugar, complete blood count and electrolyte urea and creatinine were essentially normal for his age. The patient’s HIV status was negative on serology testing.
This patient was started on hourly topical natamycin (5%), ciprofloxacin (0.3%), two-hourly instillation of tobramycin (0.3%) and atropine (1%) twice daily. He was also placed on oral fluconazole (200 mg) daily, 250 mg of acetazolamide daily and oral analgesics, all for three months following the isolation of the fungus. Despite the duration of use of the medication, the patient’s vision did not improve, as the visual acuity remained hand movement in the right eye (unaided and aided) and healed with a corneal scar.
Keratomycosis caused by C. lichenicola is rare in humans and challenging to manage. Although voriconazole has been used with success in some reports in managing C. lichenicola,8 its accessibility in our setting is limited. Generally, there is lack of access to some specific antimicrobial agents needed for possible successful treatment of infections (such as this) in low- and middle-income countries such as Nigeria.9 Although the circumstance following the occurrence of the fungus in this patient could not be fully ascertained, farming has been associated with keratomycosis.2