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BRIEF REPORT
Year : 2002  |  Volume : 50  |  Issue : 3  |  Page : 215-216

Penicillium keratitis in vernal Keratoconjunctivitis.


Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India

Correspondence Address:
R Arora
Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


PMID: 12355698

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  Abstract 

We report a case of penicillium keratitis in vernal shield ulcer in the absence of corticosteroid use. This report illustrates super-added infection in vernal shield ulcer by an organism which is otherwise innocuous and forms a part of the normal ocular flora.

Keywords: Shield ulcer, vernal keratoconjunctivitis, Penicillium.


How to cite this article:
Arora R, Gupta S, Raina UK, Mehta DK, Taneja M. Penicillium keratitis in vernal Keratoconjunctivitis. Indian J Ophthalmol 2002;50:215-6

How to cite this URL:
Arora R, Gupta S, Raina UK, Mehta DK, Taneja M. Penicillium keratitis in vernal Keratoconjunctivitis. Indian J Ophthalmol [serial online] 2002 [cited 2020 Jun 3];50:215-6. Available from: http://www.ijo.in/text.asp?2002/50/3/215/14782

Vernal Keratoconjunctivitis (VKC) is an ocular allergic manifestation characterised by bilateral seasonal inflammation of the conjunctiva and papillary hypertrophy in the tarsal and/or the limbal region. It usually affects young people and is commonly seen in dry, warm climates.[1]

Corneal involvement in vernal keratoconjunctivitis may take the form of punctate epithetial erosions, punctate epithelial keratitis, pannus and pseudogerontoxon.[1],[2] In severe cases, the epithelial erosions may coalesce to form vernal corneal ulcers, also known as shield ulcers.[2] They are seen in 3-4% of cases[3] and are usually sterile.[1] Bacterial superinfection has been reported rarely in vernal shield ulcers.[1],[2],[4] Fungal corneal ulcers occur in 0.8% of patients with vernal keratoconjunctivitis.[5] Chronic topical corticosteroid use and corneal trauma have been identified as risk factors for mycotic keratitis in such patients. An isolated case of fungal keratitis has been reported in a patient with vernal conjunctivitis without any preceding corneal trauma or corticosteroid use.[6] We now report an unusual case of fungal keratitis by Penicillium, with concomitant severe vernal keratoconjunctivitis.


  Case report Top


A 12-year-old boy presented in July 1999 with a history of severe photophobia, moderate pain, itching and decreased vision in the right eye of 2 months' duration. There was no significant medical history. There was no history of corneal injury or topical corticosteroid use preceding the present ocular complaints.

Ophthalmic examination revealed uncorrected visual acuity of counting fingers at 1 meter in the right eye and 6/12 in the left eye. The right eye showed mild ciliary congestion. A 4 mm x 5mm raised creamy white infiltrate was seen in the superior cornea, obscuring part of the pupil [Figure:1a]. It involved less than half the stromal thickness. The surrounding cornea was non-oedematous. There was minimal anterior chamber reaction. Endothelial plaque, hypopyon or satellite lesions were not noted. The cornea in the left eye lacked lustre and had superficial scars. Conjunctival examination of the right eye revealed giant cobblestone papillae in the upper tarsal conjunctiva bilaterally [Figure:1b]. The bulbar conjunctiva was dirty and muddy in both eyes. There was no limbal involvement in either eye. Schirmers test with 4% xylocaine was 6mm in the right eye and 7mm in the left eye after 5 minutes. Fundus examination and intraocular pressure measurement was unremarkable in both the eyes. The patient had received treatment with various combinations of antibiotics before being referred to us. However, there was no history of corticosteroids use.


  Results Top


Scrapings obtained from the corneal infiltrate from the base and margin of the ulcer showed fungal hyphae on a 10% Potassium Hydroxide mount (KOH mount). Gram stain of the smear did not reveal any bacteria. Culture on Sabourad dextrose agar at one week showed green, fast growing fungal colonies. On microscopic examination chains of single cell conidia borne on philades, produced on metulae, with a brush-like appearance were observed. They were identified as Penicillium. The patient was started on topical amphotericin B 0.15% and natamycin 5% suspension every hour along with cyclopentolate 1%, three times a day in the right eye. Additionally, sodium cromoglycate 2% drops four times a day and ocular lubricants four times a day were instituted for both eyes. Topical corticosteroids were withheld from the beginning since the ulcer was suspected to be infective. Instead, topical 0.03% flurbiprofen eye drops 4-hourly were started as effective nonsteroidal anti-inflammatory agents in both eyes.

The corneal infiltrate resolved completely in 4 weeks leaving a tongue-shaped superficial vascularised scar extending from the limbus to the central cornea overlying the pupil [Figure:1c]. The visual acuity improved to counting fingers at 3 metres.


  Discussion Top


The characteristic shield ulcer of VKC is superficial, sterile, horizontally oval in the superior third of the cornea.[1] Ulcer bed may have grayish opacification with elevated margins. Mechanical trauma to the corneal epithelium by giant papillae in the upper palpebral conjunctiva and the inflammatory mediators play a role in the pathogenesis of the shield ulcer.[1],[2]

Bacterial superinfection has been reported occasionally in ulcerative vernal keratoconjunctivitis.[1],[4] The most common isolated organism is Staphylococcus aureus, and there is also a high incidence of polymicrobial infection.[2],[4] This has been attributed to abnormalities of the immune system coupled with frequent use of topical corticosteroids in these patients.[2]

Fungal keratitis has been rarely reported with vernal keratoconjunctivitis. It is rare in the absence of chronic steroid use or corneal trauma.[6],[7] Other predisposing factors to fungal keratitis have been superficial punctate keratitis and/or tear film instability with reduced tear formation. Fusarium and Aspergillus have been isolated in earlier reports. The only existing report of fungal keratitis in vernal keratoconjunctivitis without corticosteroid use is in a known case of vernal keratoconjunctivitis on regular follow up[6] (Medline search). The causative organism was Aspergillus fumigatus.

The patient in this report presented with fungal keratitis in the right eye. The conjunctival findings of giant cobblestone papillae in both eyes suggestive of severe vernal keratoconjunctivitis were incidentally picked up. There was no history of topical corticosteroid use. The patient was not diagnosed earlier to have VKC. The causative organism was identified Penicillium, a relatively infrequent cause of fungal keratitis contributing to less than 10% of cases.[8]

]Penicillium spores have been identified in normal ocular flora.[8] In the absence of other predisposing factors such as topical corticosteroid use and corneal trauma, the altered immune status of VKC along with loss of physical epithelial barrier due to the shield ulcer and tear film insufficiency probably contributed to infection by this opportunistic pathogen.

The case reported is of a particularly rare and unusual nature as the causative organism for the superadded infection Penicillium, is otherwise a part of the normal ocular flora. The organisms isolated in the earlier reports are pathogenic fungi (Fusarium and Asperigllus). This report highlights that VKC per se is a contributory factor, other than the corticosteroid use and trauma, in increasing the risk of corneal infection even by innocuous organisms.

 
  References Top

1.
Allansmith MR. Vernal conjunctivitis. In: Tasman W, Jeiger EA, editors. Duane's Clinical Ophthalmology. Philadelphia: J B Lippincott, 1994; Vol. 4. pp 1-8.  Back to cited text no. 1
    
2.
Cameron JA. Shield ulcers and plaques of the cornea in vernal keratoconjunctivitis. Ophthalmology 1995;102:985-93.  Back to cited text no. 2
[PUBMED]    
3.
Neumann E, Gutmann MJ, Blumenkrantz N, Michaelson IC. A review of four hundred cases of vernal conjunctivitis. Am J Ophthalmol 1959;47:166-72.  Back to cited text no. 3
[PUBMED]    
4.
Kerr N, Stern GA. Bacterial keratitis associated with vernal keratoconjunctivitis. Cornea 1992;11:355-59.  Back to cited text no. 4
[PUBMED]    
5.
Rosa RH, Miller D, Alfonso EC. The changing spectrum of fungal keratitis in South California. Ophthalmology 1994;101:1005-13.  Back to cited text no. 5
    
6.
Gupta A, Sharma A, Mohan K, Gupta A. Mycotic keratitis in non-steroid exposed vernal keratoconjunctivitis. Acta Ophtha1mo1 Scand 1999;77:229-31.  Back to cited text no. 6
    
7.
Vajpayee R.B, Gupta S.K, Bareja U, Kishore K. Ocular atopy and mycotic keratitis. Ann Ophthalmology 1990;22:369-72.  Back to cited text no. 7
    
8.
DeVoe AG, Silva - Hutner M. Fungal infections of the eye. In: Locatcher- Khorazo D, Seegal BC, editors. Microbiology of the Eye. St. Louis: CV Mosby; 1972. pp 208-40.  Back to cited text no. 8
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]


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