2009 OMIG, Abstract 6

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Multidrug Resistant Fusarium Keratitis Progressing to Endophthalmitis.
S.L. Edelstein, H. Hsu, L. Akduman
St. Louis University Eye Institute, St. Louis University, St. Louis, MO

Purpose: To report a case of multidrug resistant Fusarium keratitis that progressed to endophthalmitis and which eventually required enucleation.
Methods: Medical records, microbiologic and histopathologic specimens were reviewed. Isolate identification and susceptibility testing were performed by the fungus testing laboratory at San Antonio, Texas.
Results: Examination of corneal scrapings taken from our patient revealed hyphae by gram stain and grew Fusarium species on culture. Antecedent risk factors included extended wear contact lens use and recent corneal abrasion. Despite aggressive antifungal therapy with topical natamycin, amphotericin B and systemic fluconazole, the keratitis progressed and a penetrating keratoplasty was performed. Recurrent infection of the corneal graft and progression to endopthalmitis was treated with repeat intravitreal amphotericin B injections, penetrating keratoplasty, pars plana vitrectomy, and finally, even after systemic use of itraconazole, voriconazole, posaconazole and topical use of voriconazole, the infection progressed and an enucleation was required. Histopathologic analysis confirmed corneal, scleral and intravitreal involvement. Isolate identification and susceptibility testing performed by the fungus testing laboratory (San Antonio, TX) found a multidrug resistant Fusarium solani, partially sensitive to natamycin only.
Conclusions: Multidrug resistant Fusarium is rare and may have devastating consequences in patients with advanced keratitis progressing to endophthalmitis. Such extensive multi-drug resistance is surprising in that resistance to antifungals is rare. Empiric antifungal therapy is usually instituted using one or more antifungal agent, without checking antifungal sensitivities. In light of growing concern for increased emergence of resistant strains, we propose a lower threshold to check for sensitivities in the face of unresponsive fungal infections.
No author has a financial or proprietary interest in any material or method mentioned.