Indian Journal of Pathology and Microbiology
Home About us Instructions Submission Subscribe Advertise Contact e-Alerts Ahead Of Print Login 
Users Online: 704
Print this page  Email this page Bookmark this page Small font sizeDefault font sizeIncrease font size


 
  Table of Contents    
CASE REPORT  
Year : 2018  |  Volume : 61  |  Issue : 4  |  Page : 607-609
Keratomycosis due to Purpureocillium lilacinum: A case report from Sub-Himalayan region of Uttarakhand


1 Department of Microbiology, Government Doon Medical College, Dehradun, Uttarakhand, India
2 Department of Microbiology, Rajshree Medical Research Institute, Bareilly, Uttar Pradesh, India
3 Department of Microbiology, Dr. Sampurnanand Medical College, Jodhpur, Rajasthan, India
4 Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
5 Department of Ophthalmology, Bundelkhand Medical College, Sagar, Madhya Pradesh, India

Click here for correspondence address and email

Date of Web Publication10-Oct-2018
 

   Abstract 


The fungus Purpureocillium lilacinum previously known as Paceliomyces lilacinus is an emerging pathogen that can cause severe human infections including devastating oculomycosis. Treatment with traditional antifungals often fails, and the organism shows variable susceptibility to novel triazoles. We hereby report a case of keratomycosis caused by Pur. lilacinum in an immunocompetent male patient following trauma. The patient was successfully treated with voriconazole. The drug shows good activity against Pur. lilacinum and could be a promising therapeutic alternative to treat infections caused by this fungus, which generally shows resistance to conventional antifungal agents including novel triazoles.

Keywords: Keratitis, oculomycosis, Paecilomyces, Purpureocillium, voriconazole

How to cite this article:
Juyal D, Pal S, Sharma M, Negi V, Adekhandi S, Tyagi M. Keratomycosis due to Purpureocillium lilacinum: A case report from Sub-Himalayan region of Uttarakhand. Indian J Pathol Microbiol 2018;61:607-9

How to cite this URL:
Juyal D, Pal S, Sharma M, Negi V, Adekhandi S, Tyagi M. Keratomycosis due to Purpureocillium lilacinum: A case report from Sub-Himalayan region of Uttarakhand. Indian J Pathol Microbiol [serial online] 2018 [cited 2018 Dec 15];61:607-9. Available from: http://www.ijpmonline.org/text.asp?2018/61/4/607/242974





   Introduction Top


Keratomycosis is a fungal infection of the cornea, characterized by inflammation often with stromal infiltration by leukocytes and is considered as an ophthalmic emergency requiring immediate attention.[1] Conventionally, it is considered a disease of rural areas and is frequently caused by trauma with the vegetative material. However, the major risk factor in developed countries is widespread use of contact lenses and topical steroid usage.[2] Filamentous fungi-like Aspergillus species and Fusarium species are the most common fungal isolates to cause keratomycosis. However, many other fungi have now emerged as an etiological agent for such infections. Paecilomyces is among the latter and is of clinical interest due to its oculotrophic nature and resistance to traditional antifungal agents.[3] Species causing human mycoses include Paecilomyces variotii, P.lilacinus, P.marquandii, P.japonicus, P.farinosus, P.taitungiacus and P. viridis.[3]

Recently, the phylogenetic analysis of the 18S rRNA gene region and partial translational elongation factor 1 α has shown the polyphyletic nature of Paecilomyces.[4] Based on the detailed phylogenetic analysis, taxonomical rearrangements have been made for genus Paecilomyces on the basis of which P. variotii is retained in the genus Paecilomyces; P. javonicus and P. farinosus have been returned to genus Isaria; P. viridis has been transferred to Chamaeleomyces; P. lilacinus is accommodated in the new genus named Purpureocillium and the new combination Purpureocillium lilacinum has been introduced; P. marquandii is currently maintained in Paecilomyces; however, this species is unrelated to P. variotii for which a new genus Paranomuraea (yet not been published validly) has been suggested.[5]

We hereby report a successfully treated case of keratomycosis caused by Pur. lilacinum (previously Paecilomyces lilacinus) in an immunocompetent host. Although cases of keratomycosis due to Purpureocillium have been reported previously from various parts of the world including India, none is reported from interiors of Uttarakhand state and to the best of our knowledge is the first case to be reported from this part of the country.


   Case Report Top


A 47-year-old male, farmer by profession experienced trauma to his right eye while working in fields. Despite receiving topical/oral antibiotics and corticosteroids from a local medical practitioner in the village his eye condition worsened, and he went to a primary health centre where he was prescribed with topical tobramycin (14 mg/ml), vancomycin (25 mg/ml), and natamycin (5%) eye drops. After 1 week therapy, his symptoms still persisted, and he was referred to our hospital a tertiary care centre.

He presented with complaints of watering, severe pain, redness, and gradual diminution of vision in the right eye. Slit lamp examination showed a stromal corneal infiltrate with ill-defined feathery margins [Figure 1]. Cornea surrounding the ulcer was hazy due to stromal edema, and the anterior chamber had a hypopyon with grade four reaction. Fundus view was hazy due to corneal infiltrate. Visual acuity (VA) of the eye was limited to hand motion at three feet. Left eye examination was within the normal limits.
Figure 1: Dense stromal infiltrate in the right eye

Click here to view


Corneal scrapings were taken by the ophthalmologist and scraped material was directly inoculated onto blood agar, chocolate agar, and Sabouraud's dextrose agar (SDA) with chloramphenicol (0.05%), making multiple “C” shape marks by a microbiologist. Smears for gram stain and 10% KOH mount were prepared right on the examination table. Inoculated blood agar and chocolate agar were incubated at 37°C and SDA at 28°C. Gram smear showed no organisms, however, few fungal elements were seen in 10% KOH mount. Based on these findings and the patient's treatment history, a presumptive diagnosis of fungal keratitis was made. The patient was put on topical fluconazole (0.1%), miconazole (0.1%) hourly, intravenous fluconazole (800 mg/day), and anti-inflammatory drugs. The patient did not respond to the therapy, and 4 days later corneal infiltrate increased in size with impending perforation.

After 72 h of incubation, fungal culture yielded the growth of a filamentous fungus. Colonies were initially white, velvety, and powdery which turned into lilac-rose-red color later [Figure 2] and as the colonies aged the color became deeper. Lactophenol cotton blue tease mount of the colony showed the presence of septate hyphae with long tapering phialides and globose conidia [Figure 3]a and [Figure 3]b. On the basis of these microscopic characters and the lilac pigment, the fungus was identified as Pur. lilacinum and the diagnosis of keratomycosis due to filamentous fungi were confirmed. The isolate was sent to Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh for molecular identification where it was confirmed to be Pur. lilacinum by amplifying and sequencing of the internal transcribed spacer (ITS1 and 2 including 5.8s region) of the ribosomal DNA using primers ITS1/ITS4 (ITS1: 5'-TCCGTAGGTGAACCTGCGG-3'; ITS4: 5'-TCCTCCGCT TAT-TGATATGC-3'). The sequence data were submitted for Basic Local Alignment Search Tool analysis at the National Center for Biotechnology Information site (http://blast.ncbi.nlm.nih.gov/blast). The Gene Bank database showed 100% identity with the Pur. lilacinum. Sequences of our isolate were submitted to GeneBank with accession number KY348744.
Figure 2: Colony of Purpureocillium lilacinum on Sabouraud's dextrose agar

Click here to view
Figure 3: (a and b) Lactophenol cotton blue tease mount of Purpureocillium lilacinum showing long tapering phialides and globose conidia

Click here to view


Considering the oculotrophic and the drug-resistant nature of the fungus, therapy was immediately changed to topical voriconazole (1%) hourly, pimaricin ointment (1%) 6 times/day and intravenous voriconazole (3 mg/kg; bd). One week later, the infiltrate diminished and became thinner. Therapeutic keratoplasty was performed with the good postoperative course. At the follow-up visit 3, 5, and 7 weeks after starting treatment, the condition of his eye showed remarkable improvement. His VA at the last visit was 1.0. No recurrence of the fungal infection has been reported to date.


   Discussion Top


Pur. lilacinum is a saprobic filamentous fungus rarely encountered as a cause of local and systemic infections in humans. Despite its apparently moderate virulence, it is able to infect both immunocompromised and immunocompetent hosts.[3]Pur. lilacinum shows a special tropism for ocular structures. In a recent review of reported Pur. lilacinum infection cases in the literature, there is a preponderance of oculomycosis (51.3%).[3] Its potential resistance to sterilizing methods, its frequent contamination of creams and lotions used clinically and its colonization of clinical materials (catheters, plastic implants etc.), increases the clinical importance of this fungus.[6] Although mortality has never been associated with primary oculomycosis caused by Pur. lilacinum, eye anucleation (38%) and endopthalmitis (25%) were the most common outcomes of the infection in previously reported cases, with favourable outcomes in only 28.3% of cases.[3] This demonstrates the potentially devastating effects of this fungus for ocular structures.

Historically, treatment of Pur. lilacinum infection has been difficult due to its intrinsic resistance to commonly used antifungals.[7] The organism is resistant to natamycin, amphotericin-B, 5-flucytosine and has variable sensitivity to imidazoles (Ketoconazole, miconazole and econazole).[8] However with the advent of newer antifungal agents such as voriconazole, albaconazole, ravuconazole, and terbinafine, the successful management of these infections is possible. However still, in many patients, medical management is not effective and ultimately surgery (penetrating keratoplasty, sclerocorneal graft, or evisceration) is required.[3],[8],[9]

In keratomycotic infections, trauma is quite commonly associated, especially when caused by vegetative matter, as in our case. Most probably, the vegetative material was previously colonized by the fungus which lead to infection following trauma. The prompt diagnosis and timely institution of appropriate therapy lead to successful management of this case. Voriconazole is a triazole antifungal agent derived from fluconazole. Studies have established voriconazole to be a valuable fungistatic agent against most yeasts in addition to many hyaline and dematiaceous filamentous fungi.[10] Although there is limited clinical experience in the use of voriconazole against Pur. lilacinum, this drug seems to be the most effective agent for the treatment of keratomycosis. Infections with this etiological agent are rare, but it is important for clinicians and microbiologists to consider the potential pathogenicity of Pur. lilacinum. Furthermore, patients showing no improvement in infiltrate despite empiric therapy in combination with corticosteroids should promptly receive voriconazole. The correct and early identification of the isolate will ensure the timely administration of appropriate therapy.

Acknowledgment

We would like to acknowledge the help extended by Dr. Arunaloke Chakrabarti, Professor and Head Department of Medical Microbiology, in charge of National Culture Collection for Pathogenic Fungi, PGIMER, Chandigarh, for the species identification and confirmation of the fungal isolate.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Karsten E, Watson SL, Foster LJ. Diversity of microbial species implicated in keratitis: A review. Open Ophthalmol J 2012;6:110-24.  Back to cited text no. 1
    
2.
Gower EW, Keay LJ, Oechsler RA, Iovieno A, Alfonso EC, Jones DB, et al. Trends in fungal keratitis in the United States, 2001 to 2007. Ophthalmology 2010;117:2263-7.  Back to cited text no. 2
    
3.
Pastor FJ, Guarro J. Clinical manifestations, treatment and outcome of Paecilomyces lilacinus infections. Clin Microbiol Infect 2006;12:948-60.  Back to cited text no. 3
    
4.
Luangsa-Ard J, Houbraken J, van Doorn T, Hong SB, Borman AM, Hywel-Jones NL, et al. Purpureocillium, a new genus for the medically important Paecilomyces lilacinus. FEMS Microbiol Lett 2011;321:141-9.  Back to cited text no. 4
    
5.
Perdomo H, Cano J, Gené J, García D, Hernández M, Guarro J, et al. Polyphasic analysis of Purpureocillium lilacinum isolates from different origins and proposal of the new species Purpureocillium lavendulum. Mycologia 2013;105:151-61.  Back to cited text no. 5
    
6.
Gutiérrez-Rodero F, Moragón M, Ortiz de la Tabla V, Mayol MJ, Martín C. Cutaneous hyalohyphomycosis caused by Paecilomyces lilacinus in an immunocompetent host successfully treated with itraconazole: Case report and review. Eur J Clin Microbiol Infect Dis 1999;18:814-8.  Back to cited text no. 6
    
7.
Yuan X, Wilhelmus KR, Matoba AY, Alexandrakis G, Miller D, Huang AJ, et al. Pathogenesis and outcome of Paecilomyces keratitis. Am J Ophthalmol 2009;147:691-6000.  Back to cited text no. 7
    
8.
Garbino J, Ondrusova A, Baglivo E, Lew D, Bouchuiguir-Wafa K, Rohner P, et al. Successful treatment of Paecilomyces lilacinus endophthalmitis with voriconazole. Scand J Infect Dis 2002;34:701-3.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
    
10.
Naik M, Mohd Shahbaaz, Sheth J, Sunderamoorthy SK. Alternaria keratitis after deep anterior lamellar keratoplasty. Middle East Afr J Ophthalmol 2014;21:92-4.  Back to cited text no. 10
[PUBMED]  [Full text]  

Top
Correspondence Address:
Deepak Juyal
Department of Microbiology, Government Doon Medical College, Dehrakhas, Patelnagar, Dehradun - 248 001, Uttarakhand
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_404_17

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed258    
    Printed5    
    Emailed0    
    PDF Downloaded30    
    Comments [Add]    

Recommend this journal