A Rare Case of Malbranchea Species Pulmonary Infection in the Setting of Suspected Selective Immunoglobulin M Deficiency

Indolent keratitis due to fungus of Malbranchea species. A case report

Introduction

Keratitis caused by saprophytic fungi is on the rise in rural areas, often caused by ocular trauma with wooden objects. Early detection of causative organisms and sustained, supervised management can prevent visual disabilities.

Case presentation

A middle-aged patient from a rural, semi-arid region who presented with pain, redness, and a foreign-body sensation in his left eye resulting from a corneal ulcer induced by trauma from a wooden stick. Due to a history of uncontrolled diabetes and progression of his corneal lesions, he was admitted to our institution for treatment of infectious keratitis. Microbiological examination of corneal scrapings revealed thin, septate hyaline hyphae without conidia or conidiophores, and the patient was diagnosed with a fungal keratitis caused by a Malbranchea species. Though the patient initially responded to treatment with topical natamycin, his condition worsened. He was subsequently successfully treated with topical amphotericin B (1 mg/mL) twice hourly and systemic antifungals. Four months after discharge, the patient returned with symptom recurrence.

Conclusion

We report the case of a patient with a Malbranchea species causing a rare and recurrent fungal keratitis with corneal infiltrates, subsequently cured by medical management with salvaging of his vision. In patients with a suspected fungal keratitis, early treatment is crucial and should be combined with tight glycemic control for as long as 6 months after presentation to avoid recurrence.

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Fungal keratitis can lead to visual disability if not treated adequately.

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Malbranchea species are rare pathogens resistant to many antifungal agents.

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Malbranchea keratitis treatment is difficult and can result in poor outcomes.

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Treating fungal keratitis is an indolent process often requiring months.

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Standard protocols are necessary for managing fungal keratitis.

Coccidioides in lung transplant: case report

A middle-aged woman was hospitalised for generalised, painful skin lesions 6 weeks after a successful double-lung transplant. She had end-stage lung disease associated with chronic obstructive pulmonary disease due to alpha-1 antitrypsin deficiency, and she had been treated with itraconazole for 16 months because of lung infection associated with Malbranchea spp. Results of a skin biopsy of the initial lesion on her arm showed non-specific dermal inflammation, presumably due to reactivation of the Malbranchea spp infection. Follow-up cervical lymph node biopsy and culture showed Coccidioides posadasii/C. immitis A detailed review of her travel history showed a 4-month stay in Arizona as a teenager that she barely remembered. Coccidioides spp were likely misidentified as Malbranchea spp owing to similar morphological characteristics. Dosages of immunosuppressive medications were reduced, and antifungal therapy was changed to posaconazole. Her skin lesions resolved.