MYCOSES
34, 489-491 (1991)
ACCEPTED:NOVEMBER 2 1, 1991
CASEREPORT
Phaeohyphomycosis of the eye caused by Exserohilum rostratum in India Phaeohyphomykose am Auge bedingt durch Exserohilum rostratum in Indien V. Anandi', J. A. George', R. Thomas', K. N. Brahmadathan' and T. J. John' Key words. Exserohilum rostratum, phaeohyphomycosis, oculomycosis, cornea, natamycin, ke toconazole. Schliisselworter. Exserohilum rostratum, Phaeohyphomykose, Augenmykose, Cornea, Natamycin, Ketoconazol.
Summary. A 40-year-old woman developed a corneal ulcer with hypopyon following a traumatic episode. In a K O H mount dematiaceous, septate, branched hyphae were demonstrated, and heavy growth of Exserohilum rostratum was obtained in culture. No bacterial pathogens were isolated. The patient was treated with natamycin and subsequently with ketoconazole. In spite of antimycotic therapy a descemetocele of the eye remained. This observation represents the first documented case of an Exserohilum infection in India. Zusammenfassung. Eine 40-jahrige Frau entwickelte nach Trauma ein Hornhautulkus mit Hypopyon. Die Untersuchung von Hornhautabschabsel ergab mikroskopisch im KOH-Praparat das Vorhandensein von verzweigten, septierten, pigmentierten Hyphen; in Kultur konnte Exserohilum rostratum geziichtet werden. Bakterielle Erreger waren nicht nachweisbar. Die Patientin wurde zunachst mit Natamycin, spater mit Ketoconazol behandelt. Trotz dieser antimykotischen Therapie verblieb eine Descemetozele des Auges. Dies ist der erste dokumentierte Fall einer Exserohilum-Infektion in Indien.
'Department of Microbiology and 'Schell Eye Hospital, Christian Medical College and Hospital, Vellore 632 004, India. Correspondence: Dr V. Anandi, Microbiology Department, CMC Hospital, Vellore 632 004, India.
Introduction
Dematiaceous fungal infections of the eye, especially those due to Curvularia lunata, C. geniculata, C. pallescens, C. senegalensis and C. verrucosa, have been increasingly reported in recent years from different parts of the world [l-51. We recently reported a case of corneal ulcer caused by Bipolaris hawaiiensis [6]. Other dematiaceous fungi causing mycotic keratitis include Alternaria, Aureobasidium, Cladosporium, Exophiala, Fonsecaea and Phialophora spp. [ 3 , 71. Among the various species of Exserohilum, only E. rostratum has been claimed as a causative agent of corneal ulcer [8]. We report here a case of corneal ulcer with hypopyon caused by E . rostratum which represents the first isolate from a human infection in India. Case history
A 40-year-old woman presented with complaints of pain, watering, redness and diminution of vision of the right eye of 10 days duration, following an injury with a paddy leaf. O n examination, the visual acuity in the right eye was grossly diminished (hand movements close to face with an accurate projection of rays). The conjunctiva showed ciliary congestion and slit lamp examination revealed an 8 mm x 5 mm dry ulcer involving the lower two-thirds of the cornea to about half thickness. There were blackish deposits on the surface of the ulcer, the border of which was irregular; four satellite lesions were
490
V. ANANDI ET
AL.
seen around the edge of the ulcer margin with a hypopyon. The digital tension appeared to be raised. The vision in the left eye was 6/6J1 and examination unremarkable. Corneal scrapings from the floor of the ulcer were subjected to microbiological investigation.
Mycology Scrapings from the cornea were brown to black. The specimen was processed for fungal and bacteriological microscopic examination and culture [5, 91. A potassium hydroxide (KOH 10%) mount and Gram-stained smears were made. The specimens were cultured on two Sabouraud glucose agar (SGA) plates, one Sabouraud glucose broth and one thioglycollate broth for fungus culture. One SGA plate was incubated at 25°C and the other at 37 "C. Bacteriological culture was carried out on blood agar, McConkey agar and chocolate agar. Results
KOH mount of the corneal scrapings showed few dematiaceous, septate, branched long fungal filaments. Gram-stained smears had no bacteria and the fungus did not take up the Gram stain. The fungal growth started appearing on the 4th day after inoculation. On the 7th day of incubation at 37°C and at 25"C, the colonies appeared grey and woolly, with the reverse side black. Lactophenol cotton blue mount of the slide culture preparations on potato dextrose agar and cornmeal agar with dextrose revealed many dematiaceous, septate, branched fungal hyphae with sympodial conidiophores (Fig. 1). The conidia were ellipsoidal with protruding hila and darkly pigmented basal and distal septa (Fig. 1). The fungus was identified as Exserohilum rostratum according to the description of McGinnis et al. [8]. Bacterial culture yielded no bacteria. Treatment
The clinical picture was suggestive of fungal etiology and treatment was initiated with hourly 5% natamycin drops, 0.9% gentamycin drops every 6th hour, 1% atropine drops every 8th hour and tablet acetazolamide 250 mg every 6th hour. Ketoconazole was added because the patient did not show any improvement with natamycin. However, the corneal ulcer did not show improvement even with 5 days of local
Figure 1. Exsnohilum rostrufum isolated from a corneal ulcer. Lactophenol cotton blue mount of a slide culture showing dematiaceous sympodial conidiophores, rowate conidia with 6 to 9 distosepta and protruding hila ( x 350).
ketoconazole (2%) drops at 2-h intervals. I t continued to worsen and a descemetocele was formed. The patient was advised surgical intervention and systemic antifungal therapy, which she refused, and was discharged against medical advice.
Discussion Demonstration of the fungus in the potassium hydroxide mount of corneal scrapings and isolation of E. rostratum in culture confirmed the clinical diagnosis of fungal etiology of the corneal ulcer. The isolate was identified as E. rostratum following the morphological features described by McGinnis et al. [8]. The sympodial conidiophores and rostrate conidia having 6 to 9 distosepta, smooth walled with protruding hila, were suggestive of an Exserohilum sp. Furthermore, presence of a characteristic deeply pigmented septum at both ends of the conidium (Fig. 1) confirmed the identification as E. rostratum. This feature is usually not present in other species of Exserohilum including E. mcginnis. Our isolate produced large numbers of conidia on cornmeal agar with glumycoses 34,489-49 1 ( 1991)
CORNEAL ULCER
cose, and potato glucose agar. McGinnis et al. [8], while reporting on the emerging agent of phaeohyphomycosis, had described the isolation of E. rostratum from biopsies of an erythematous nodule on the right leg of a female patient who had undergone a cardiac transplant. In their description they list only one case of corneal ulcer caused by E. rostratum. To the best of our knowledge no other cases have been reported in the literature. Thus the present case report is the second case of corneal ulcer due to E. rostratum. Moreover this represents the first such case report from India. The occurrence of this fungus in Australia and the USA has been documented
PI
*
The corneal ulcer did not resolve following antifungal therapy and it resulted in a descemetocele of the eye. The 10-day clinical history of infection of the cornea in this patient reflects the fact that E. rostratum is a potential pathogen and it can cause considerable damage to the eye if it is not treated early.
Acknowledgement We kindly acknowledge the secretarial help of Ms S. Dhanalakshmi and the help in computer work of M r Sathish.
This journal is available on Fourteen working days after receipt of this issue at the ADONIS offices in Amsterdam, the entire contents will be available on CD-ROM. Subscribers to the ADONIS system will then be able to search the database and view individual pages, either on screen or as laser-printed hard copy. ADONIS was introduced in 1987 on a two-year trial period at 13 libraries in 10 countries. The savings in photocopy costs, storage space and staff time were found to be very significant and the 16dlgil ADONIS number has proved to be superior to earlier systems for document retrieval. Encouraged by the results of the trial, the ADONIS board decided to introduce a commercial service, com-
mycoses 34,489-491 (1991)
DUE TO
EXSEROHILUM ROSTRATUM
491
References 1 Forster, R. K., Rebell, G. & Wilson, L. A. (1975) Dematiaceous fungal keratitis. Clinical isolates and management. Br. 3. Ophthalmol. 59, 372-376. 2 Nityananda, K., Sivasubramanium, P. & Ajello, L. (1964) A case of mycotic keratitis caused by Curvulana lunata. Sabouraudia 2, 35-39. 3 Nityananda, K., Sivasubramanium, P. & Ajello, L. (1964) A case of mycotic keratitis caused by Curuularia geniculata. Archives of Ophthalmology 65, 89-96. 4 Prasad, S. & Nema, W. V. (1982) Mycotic infections of cornea. Id.J. Ophthalmol. 30,81-85. 5 Rippon, J. W. (1988) Phaeohyphomycosis. Chapter 10. In: Wonsiewicz, M. (ed.) Medical mycology the pathogenic fungi and the pathogenic Actinomycetes. 3rd edn. W. B. Saunders & Company, Harcourt Brace Jovanovich, Inc., pp. 297-324. 6 Anandi, V., Suryawanshi, N. B., Koshi, G., Padhye, A. A. & Ajello, L. (1988) Corneal ulcer caused by Bipolaris hawaiiensis. 3. Med. Vef. Mycol. 26, 301-306. 7 Zapater, R. C. (1980) Keratomycosis caused by dematiaceous fungi. In: Superficial cutaneous and subcutaneour infections. Washington, D.C.: Pan American Health Organization, Scientific Publication No. 396, pp. 82-87. 8 McGinnis, M. R., Rinaldi, M. G. & Winn, R. E. (1986) Emerging agents of phaeohyphomycosis: pathogenic species of Bipolaris and Exserohilum. 3. Clin. Minobiol. 24, 150- 159. 9 Rebell, G. & Forster, R. K. (1980) Fungi of Keratomycosis. In: Lennette E. H., Balows, A., Hauslor, W. J. Jr. & Truant, J. P. (eds) Manual of Clinical Microbiology, 3rd edn. American Society for Microbiology, Washington D.C., pp. 553-561.
TM
mencing with journals published in 1991. The result is a 'tailor-made' document delivery service, aimed initially at the pharmaceutical industry. From the outset, ADONIS has benefited from the firm support of both publishers and libraries. This continued support is allowing the system to grow and develop, enhancing the quality, speed and efficiency of document delivery worldwide.
For futther informatlon,please contact: ADONIS Tel: +31-20-6842206 Telefax: 4 1-20-6880241 PO Box 839 1000 AV Amsterdam Telex: 18582nl The Netherlands E-Mail: 27:ESX004
34, 489-491 (1991)
ACCEPTED:NOVEMBER 2 1, 1991
CASEREPORT
Phaeohyphomycosis of the eye caused by Exserohilum rostratum in India Phaeohyphomykose am Auge bedingt durch Exserohilum rostratum in Indien V. Anandi', J. A. George', R. Thomas', K. N. Brahmadathan' and T. J. John' Key words. Exserohilum rostratum, phaeohyphomycosis, oculomycosis, cornea, natamycin, ke toconazole. Schliisselworter. Exserohilum rostratum, Phaeohyphomykose, Augenmykose, Cornea, Natamycin, Ketoconazol.
Summary. A 40-year-old woman developed a corneal ulcer with hypopyon following a traumatic episode. In a K O H mount dematiaceous, septate, branched hyphae were demonstrated, and heavy growth of Exserohilum rostratum was obtained in culture. No bacterial pathogens were isolated. The patient was treated with natamycin and subsequently with ketoconazole. In spite of antimycotic therapy a descemetocele of the eye remained. This observation represents the first documented case of an Exserohilum infection in India. Zusammenfassung. Eine 40-jahrige Frau entwickelte nach Trauma ein Hornhautulkus mit Hypopyon. Die Untersuchung von Hornhautabschabsel ergab mikroskopisch im KOH-Praparat das Vorhandensein von verzweigten, septierten, pigmentierten Hyphen; in Kultur konnte Exserohilum rostratum geziichtet werden. Bakterielle Erreger waren nicht nachweisbar. Die Patientin wurde zunachst mit Natamycin, spater mit Ketoconazol behandelt. Trotz dieser antimykotischen Therapie verblieb eine Descemetozele des Auges. Dies ist der erste dokumentierte Fall einer Exserohilum-Infektion in Indien.
'Department of Microbiology and 'Schell Eye Hospital, Christian Medical College and Hospital, Vellore 632 004, India. Correspondence: Dr V. Anandi, Microbiology Department, CMC Hospital, Vellore 632 004, India.
Introduction
Dematiaceous fungal infections of the eye, especially those due to Curvularia lunata, C. geniculata, C. pallescens, C. senegalensis and C. verrucosa, have been increasingly reported in recent years from different parts of the world [l-51. We recently reported a case of corneal ulcer caused by Bipolaris hawaiiensis [6]. Other dematiaceous fungi causing mycotic keratitis include Alternaria, Aureobasidium, Cladosporium, Exophiala, Fonsecaea and Phialophora spp. [ 3 , 71. Among the various species of Exserohilum, only E. rostratum has been claimed as a causative agent of corneal ulcer [8]. We report here a case of corneal ulcer with hypopyon caused by E . rostratum which represents the first isolate from a human infection in India. Case history
A 40-year-old woman presented with complaints of pain, watering, redness and diminution of vision of the right eye of 10 days duration, following an injury with a paddy leaf. O n examination, the visual acuity in the right eye was grossly diminished (hand movements close to face with an accurate projection of rays). The conjunctiva showed ciliary congestion and slit lamp examination revealed an 8 mm x 5 mm dry ulcer involving the lower two-thirds of the cornea to about half thickness. There were blackish deposits on the surface of the ulcer, the border of which was irregular; four satellite lesions were
490
V. ANANDI ET
AL.
seen around the edge of the ulcer margin with a hypopyon. The digital tension appeared to be raised. The vision in the left eye was 6/6J1 and examination unremarkable. Corneal scrapings from the floor of the ulcer were subjected to microbiological investigation.
Mycology Scrapings from the cornea were brown to black. The specimen was processed for fungal and bacteriological microscopic examination and culture [5, 91. A potassium hydroxide (KOH 10%) mount and Gram-stained smears were made. The specimens were cultured on two Sabouraud glucose agar (SGA) plates, one Sabouraud glucose broth and one thioglycollate broth for fungus culture. One SGA plate was incubated at 25°C and the other at 37 "C. Bacteriological culture was carried out on blood agar, McConkey agar and chocolate agar. Results
KOH mount of the corneal scrapings showed few dematiaceous, septate, branched long fungal filaments. Gram-stained smears had no bacteria and the fungus did not take up the Gram stain. The fungal growth started appearing on the 4th day after inoculation. On the 7th day of incubation at 37°C and at 25"C, the colonies appeared grey and woolly, with the reverse side black. Lactophenol cotton blue mount of the slide culture preparations on potato dextrose agar and cornmeal agar with dextrose revealed many dematiaceous, septate, branched fungal hyphae with sympodial conidiophores (Fig. 1). The conidia were ellipsoidal with protruding hila and darkly pigmented basal and distal septa (Fig. 1). The fungus was identified as Exserohilum rostratum according to the description of McGinnis et al. [8]. Bacterial culture yielded no bacteria. Treatment
The clinical picture was suggestive of fungal etiology and treatment was initiated with hourly 5% natamycin drops, 0.9% gentamycin drops every 6th hour, 1% atropine drops every 8th hour and tablet acetazolamide 250 mg every 6th hour. Ketoconazole was added because the patient did not show any improvement with natamycin. However, the corneal ulcer did not show improvement even with 5 days of local
Figure 1. Exsnohilum rostrufum isolated from a corneal ulcer. Lactophenol cotton blue mount of a slide culture showing dematiaceous sympodial conidiophores, rowate conidia with 6 to 9 distosepta and protruding hila ( x 350).
ketoconazole (2%) drops at 2-h intervals. I t continued to worsen and a descemetocele was formed. The patient was advised surgical intervention and systemic antifungal therapy, which she refused, and was discharged against medical advice.
Discussion Demonstration of the fungus in the potassium hydroxide mount of corneal scrapings and isolation of E. rostratum in culture confirmed the clinical diagnosis of fungal etiology of the corneal ulcer. The isolate was identified as E. rostratum following the morphological features described by McGinnis et al. [8]. The sympodial conidiophores and rostrate conidia having 6 to 9 distosepta, smooth walled with protruding hila, were suggestive of an Exserohilum sp. Furthermore, presence of a characteristic deeply pigmented septum at both ends of the conidium (Fig. 1) confirmed the identification as E. rostratum. This feature is usually not present in other species of Exserohilum including E. mcginnis. Our isolate produced large numbers of conidia on cornmeal agar with glumycoses 34,489-49 1 ( 1991)
CORNEAL ULCER
cose, and potato glucose agar. McGinnis et al. [8], while reporting on the emerging agent of phaeohyphomycosis, had described the isolation of E. rostratum from biopsies of an erythematous nodule on the right leg of a female patient who had undergone a cardiac transplant. In their description they list only one case of corneal ulcer caused by E. rostratum. To the best of our knowledge no other cases have been reported in the literature. Thus the present case report is the second case of corneal ulcer due to E. rostratum. Moreover this represents the first such case report from India. The occurrence of this fungus in Australia and the USA has been documented
PI
*
The corneal ulcer did not resolve following antifungal therapy and it resulted in a descemetocele of the eye. The 10-day clinical history of infection of the cornea in this patient reflects the fact that E. rostratum is a potential pathogen and it can cause considerable damage to the eye if it is not treated early.
Acknowledgement We kindly acknowledge the secretarial help of Ms S. Dhanalakshmi and the help in computer work of M r Sathish.
This journal is available on Fourteen working days after receipt of this issue at the ADONIS offices in Amsterdam, the entire contents will be available on CD-ROM. Subscribers to the ADONIS system will then be able to search the database and view individual pages, either on screen or as laser-printed hard copy. ADONIS was introduced in 1987 on a two-year trial period at 13 libraries in 10 countries. The savings in photocopy costs, storage space and staff time were found to be very significant and the 16dlgil ADONIS number has proved to be superior to earlier systems for document retrieval. Encouraged by the results of the trial, the ADONIS board decided to introduce a commercial service, com-
mycoses 34,489-491 (1991)
DUE TO
EXSEROHILUM ROSTRATUM
491
References 1 Forster, R. K., Rebell, G. & Wilson, L. A. (1975) Dematiaceous fungal keratitis. Clinical isolates and management. Br. 3. Ophthalmol. 59, 372-376. 2 Nityananda, K., Sivasubramanium, P. & Ajello, L. (1964) A case of mycotic keratitis caused by Curvulana lunata. Sabouraudia 2, 35-39. 3 Nityananda, K., Sivasubramanium, P. & Ajello, L. (1964) A case of mycotic keratitis caused by Curuularia geniculata. Archives of Ophthalmology 65, 89-96. 4 Prasad, S. & Nema, W. V. (1982) Mycotic infections of cornea. Id.J. Ophthalmol. 30,81-85. 5 Rippon, J. W. (1988) Phaeohyphomycosis. Chapter 10. In: Wonsiewicz, M. (ed.) Medical mycology the pathogenic fungi and the pathogenic Actinomycetes. 3rd edn. W. B. Saunders & Company, Harcourt Brace Jovanovich, Inc., pp. 297-324. 6 Anandi, V., Suryawanshi, N. B., Koshi, G., Padhye, A. A. & Ajello, L. (1988) Corneal ulcer caused by Bipolaris hawaiiensis. 3. Med. Vef. Mycol. 26, 301-306. 7 Zapater, R. C. (1980) Keratomycosis caused by dematiaceous fungi. In: Superficial cutaneous and subcutaneour infections. Washington, D.C.: Pan American Health Organization, Scientific Publication No. 396, pp. 82-87. 8 McGinnis, M. R., Rinaldi, M. G. & Winn, R. E. (1986) Emerging agents of phaeohyphomycosis: pathogenic species of Bipolaris and Exserohilum. 3. Clin. Minobiol. 24, 150- 159. 9 Rebell, G. & Forster, R. K. (1980) Fungi of Keratomycosis. In: Lennette E. H., Balows, A., Hauslor, W. J. Jr. & Truant, J. P. (eds) Manual of Clinical Microbiology, 3rd edn. American Society for Microbiology, Washington D.C., pp. 553-561.
TM
mencing with journals published in 1991. The result is a 'tailor-made' document delivery service, aimed initially at the pharmaceutical industry. From the outset, ADONIS has benefited from the firm support of both publishers and libraries. This continued support is allowing the system to grow and develop, enhancing the quality, speed and efficiency of document delivery worldwide.
For futther informatlon,please contact: ADONIS Tel: +31-20-6842206 Telefax: 4 1-20-6880241 PO Box 839 1000 AV Amsterdam Telex: 18582nl The Netherlands E-Mail: 27:ESX004
