Keratomycosis due to Trichophyton mentagrophytes

Simultaneous dermatophytosis and keratomycosis caused by Trichophyton interdigitale infection: a case report and literature review

Background

Dermatophytosis is a fungal infectious disease caused by dermatophytes, which produce protease and keratinase to digest keratin, leading to the colonization, invasion, and infection of the stratum corneum of the skin, hair shafts, and nails. Trichophyton interdigitale belongs to Trichophyton mentagrophytes complex, which is the common pathogen causing dermatophytosis. Fungal keratitis, also called keratomycosis, is an infectious disease of cornea.

Case presentation

Here, we report a case of simultaneous dermatophytosis and keratomycosis caused by Trichophyton interdigitale. A 67-year-old man presented with extensive erythema all over the body since 4 years ago, fungal infection of left eye for 2 years, and loss of vision in the eye. These symptoms had become aggravated in the last month. Dermatological examinations showed extensive erythematous plaques with clear borders and scales, scattered red papules with ulceration, and scabs throughout the body. Onychomycosis was observed on the nails of left hand, conjunctival infection with secretion and loss of vision were noted in left eye. Hyaline septate hyphae were observed under direct microscopic examination, fungal culture and internal transcribed spacer sequencing revealed T. interdigitale. Histopathological examination suggested infectious granuloma. A diagnosis of dermatophytosis and keratomycosis caused by T. interdigitale with loss of vision in left eye was made. The patient was treated with luliconazole cream (two applications per day) and itraconazole (100 mg, BID, PO). Complete clinical remission was achieved after 1 month. Subsequently, the patient underwent left eye enucleation in the ophthalmology department.

Conclusions

In the present study, we reported a case of simultaneous dermatophytosis and keratomycosis caused by T. interdigitale, and reviewed the literature on corneal infection caused by Trichophyton. A total of 10 articles with 45 patients were published between 1973 and 2018. The pathogen of 27 patient were identified to species level. There were T. schoenleinii (17), T. mentagrophytes (4), T. verrucosum (3), T. rubrum (1), T. erinacei (1), and T. interdigitale (1). Five patients had corneal trauma, one had contact lens use history. Direct microscopic examination, fungal culture, and analysis of physiological characteristics were the main methods of identification. Early diagnosis and prompt treatment may help improve the management and outcomes.

Keratomycosis: Etiology, Risk Factors and Differential Diagnosis- A Mini Review on Trichophyton spp

Fungal keratitis is an infectious disease of the cornea. Lack of suspicion and delayed diagnosis herald the onset of complications often leading to permanent loss of vision or worse, enucleation. While a variety of pathogenic fungi especially non-dermatophyte molds associated with fungal keratitis have been identified, a comprehensive review identifying the Trichophyton spp. has not been completed. Trichophyton spp. is a rare but important entity implicated in fungal keratitis. Case reports from around the world designate it as a dangerous pathogen. Trichophyton spp. implicated in keratitis has not previously been reported and is considerably greater than suggested by incidence studies. Patient outcome is heavily reliant upon correct identification, timely intervention and effective treatment. Species identification, the risk factors associated with, and pathogenesis of keratitis will allow the development of improved therapies. This mini review provides a resource for clinicians and researchers to recognize Trichophyton spp. as a potent etiological agent capable of causing keratitis. It is no more a dermatophyte limited to infection of appendages.

A case of fungal keratitis and onychomycosis simultaneously infected by Trichophyton species

BACKGROUND

Fungal keratitis is difficult to treat that can result in corneal blindness requiring penetrating keratoplasty and in fungal endothalmitis. We report a case of fungal keratitis and onychomycosis simultaneously infected by Trichophyton.

CASE PRESENTATION

A 77-year old male presented with ocular pain, conjunctival injection, and severe loss of vision in his left eye. His best corrected visual acuity was hand movements in the left eye, and slit-lamp examination showed a corneal ulcer with feathery margin and hypopyon. Bacterial and fungal smear/culture showed no organism, and there was no improvement in spite of treatment with topical fortified 5% cefazolin and 2% tobramycin. Trichophyton species was identified by repeated cultures. We found onychomycosis on the patient's foot, where the same fungal species were identified. Regimen was changed to topical itraconazole and systemic intravenous itraconazole. No clinical improvement was observed, so therapeutic penetrating keratoplasty and cryotherapy was done with continuation of antifungal therapy. The graft was clear at postoperative 1 month and no evidence of recurrence was found.

CONCLUSION

It is important to identify the pathogen of keratitis because early identification of pathogen causing keratitis provides the appropriate treatment in early phase of keratitis. It is necessary to search for other fungal skin infections such as onychomycosis and athelete's foot considering the fungal keratitis following skin infection. In addition, fungal skin infection including onychomycosis should be treated for prevention of fungal keratitis as soon as possible.

Ocular mycosis at a referral center in Saudi Arabia: A 20-year study

PURPOSE

To review the clinical experience of fungal keratitis cases at King Khaled Eye Specialist Hospital (KKESH) in Riyadh, Saudi Arabia.

METHODS

Retrospective observational review and analysis of 124 patient charts with confirmed diagnosis of fungal keratitis between 1984 and 2004.

RESULTS

One hundred and twenty four eyes of 124 patients had proven fungal infection; 101 eyes had fungal keratitis and 23 eyes had fungal endophthalmitis complicating keratitis. Estimated proportion of fungal keratitis and endophthalmitis was 10.3%. Mean age was 55 years with male predominance (79.0%). Commonly associated factors were previous intraocular surgery (38.7%) and trauma (20.9%). Major risk factor for progressing to endophthalmitis was previous intraocular surgery (65.2%), p < 0.001. Initial laboratory results were fungal positive only in 30.6% (p < 0.001). Commonest organisms isolated were Aspergillus spp. (29.8%) followed by Trichophyton sp. (16.1%), then Candida and Fusarium sp. Comparison of both phases of the study showed improvement in the rate of successfully treated cases from 34.6% to 58.3%, and a decline in cases progressing to endophthalmitis from 25.0% to 13.9%. Therapeutic penetrating keratoplasty increased from 26.9% to 73.6% (p < 0.001). Thirteen eyes required enucleation or evisceration.

CONCLUSIONS

In contrast to other studies on fungal keratitis, Aspergillusspp. and Trichophyton sp. were the most commonly isolated fungal pathogens; the former carries the worst prognosis. Risk factors included previous intraocular surgery and trauma. Poor outcome was associated with Aspergillus spp., delayed presentation, previous intraocular surgery and late surgical intervention. This study recommends early surgical intervention to improve the outcome.

Traditional medicine in oman: its role in ophthalmology

Aim:

To present three patients with ocular disease who developed a range of complications following use of traditional medications.

Settings and Design:

Case series

Methods:

Three patients who were examined in the Ophthalmic department of a tertiary care teaching hospital in the Sultanate of Oman between 2003 and 2004, seeking care following use of traditional medicines and or healing practices for various ophthalmic problems described below.

Results:

The first patient was a computer professional with a chalazion; the patient used a plant extract from ‘Calotropis procera’ as a part of the treatment. He developed corneal edema with decrease in vision in his left eye following application of the plant extract. Treatment with topical steroids and antibiotics resulted in a complete clinical and visual recovery. The second patient developed a fungal corneal ulcer (dermatophyte - Trichophyton mentagrophyte) after sustaining injury with an animal tail to the right eye and used honey for pain relief prior to presentation. She responded poorly to anti-fungal treatment, underwent a penetrating keratoplasty with recurrence of infection in the graft that resulted in a vascularized corneal scar. The third patient was a five-year-old child who was treated with ‘wasam’ on the occiput for intraocular inflammation following bilateral uncomplicated cataract extraction. Following this treatment the topical steroid was discontinued. The ‘Wasam’ treatment indirectly resulted in exacerbation of the intraocular inflammation and secondary glaucoma and poor vision as well as ‘Wasam ulcers’ on the occiput. Despite treatment of the intraocular inflammation, the visual outcome was poor.

Conclusion:

Traditional medicine in Oman is sought by many for variable reasons. Lack of evidence-based scientific data on its safety or efficacy does not deter the Omanis from flocking the traditional healers. However, when applied in the treatment of ocular diseases, traditional medicine and healing practices seem to cause more harm than benefit for the patient.

Mikrobielle Keratitis

PURPOSE

To determine the risk factors and the influence of complementary/alternative medicines (CAM) for infectious keratitis in a monsoon-free region of the Sultanate of Oman.

STUDY DESIGN

Retrospective single center cohort study.

OUTCOME MEASURES

Demographic data, risk factors, and pathogens.

METHODS

Patients with purulent stromal keratitis admitted from 2001-2004 were evaluated for clinical and microbiological data, CAM use, duration of hospitalization, and outcome of treatment.

STATISTICS

chi(2)-test, Z-test.

RESULTS

A total of 320 patients (326 eyes) out of 7,524 admissions had severe infectious stromal keratitis requiring inpatient treatment. The average age was 35.1+/-2.5 years (range 1.5-63 years), the male:female ratio was 2:3 in the age group >or=13 years and 2:1 in the age group <or=12 years. Unsuccessful treatment by traditional healers prior to presentation was recorded for 203 patients (62.3%). Ocular risk factors included severe trachomatous dry eye conditions, meibomianitis and soft contact lens overwear. Systemic compromising risk factors were diabetes mellitus and medical immunosuppression. A total of 215 patient eyes (66%) had delayed or no healing (therapy drop-outs), and hospitalization (45 days) was significantly prolonged compared to the 111 antibiotic responders (26 days) (p<0.001). All eyes of patients with prior CAM had worse vision at admission and after therapy (p<0.001), and 97 eyes of patients with uncontrolled diabetes (p<0.001) and 68 eyes of patients with immunosuppression (p<0.001) had a poor visual outcome (vision <0.1). Thirteen eyes perforated. A negative microbiological result correlated with worse final vision (p<0.05). All 13 perforated eyes had received prior CAM (p<0.001).

CONCLUSIONS

Trachoma, trauma and contact lens overwear are significant risk factors for infectious keratitis in Oman and correlate with specific age groups. Delay in treatment due to the first-line utilization of CAM showed a significant adverse impact on outcome.

Emerging fungal diseases: the importance of the host

More yeasts and molds are now recognized to cause more human disease than ever before. This development is not due to a change in the virulence of these fungi, but rather to changes in the human host. These changes include immunosuppression secondary to the pandemic of HIV, the use of life-saving advances in chemotherapy and organ transplantation, and the use of corticosteroids and other immunosuppressive agents to treat a variety of diseases. Fungi that were once considered common saprophytes are now recognized as potential pathogens in these patients. This situation necessitates better communication than ever between the clinician, pathologist, and clinical mycologist to ensure the prompt and accurate determination of the cause of fungal diseases.