Clinicopathologic spectrum of mycotic keratitis

Clinical Research

Spectrum of fungal keratitis: clinicopathologic study of

44 cases

1
Department of Pathology, Government Medical College and preliminary diagnosis. Early administration of antifungal
Hospital, Sector 32-A, Chandigarh 160030, India treatment helps in preventing dreadful complications.
2
Department of Microbiology, Government Medical College KEYWORDS: mycotic keratitis; fungal; culture; infection;
and Hospital, Sector 32-A, Chandigarh 160030, India cornea
Department of Ophthalmology, Government Medical DOI:10.3980/j.issn.2222-3959.2014.01.21
3

College and Hospital, Sector 32-A, Chandigarh 160030, India

Correspondence to: Reetu Kundu. Department of Pathology, Punia RS, Kundu R, Chander J, Arya SK, Handa U, Mohan H.
Government Medical College and Hospital, Sector 32-A, Spectrum of fungal keratitis: clinicopathologic study of 44 cases.
Chandigarh 160030, India. [email protected] 2014;7(1):114-117
Received: 2013-07-31 Accepted: 2013-09-13
INTRODUCTION
Abstract
AIM: To determine the causative agents of fungal
M ycotic keratitis has been reported from many different
parts of the world, with a worldwide reported
incidence varying from 17% to 36% in various studies [1]. It is
keratitis and study the predisposing factors over a period
particularly common in tropical areas, where the incidence
of ten years in a single tertiary care hospital.
ranges between 14% -40% of all ocular mycoses, or of all
METHODS: A retrospective analysis of fungal corneal
cases of microbial keratitis [2] . The incidence in India is 44%
ulcers was done from 2003 -2012. Patients' clinical data to 47%[1] . Fungal corneal ulcer is common in India due to the
were noted from the file records. Correlation of
tropical climate and a large agrarian population that is at
histopathological diagnosis was done with the report on
risk [3] . Keratomycosis can be caused by as many as 60
fungal culture.
species of fungi [4]. The time interval from trauma to clinical
RESULTS: Mycotic keratitis was established in 44 features varies depending on the organism, the size of
cases by a positive fungal culture. Direct microscopic inoculum and host resistance.
examination of potassium hydroxide (KOH) mounts Such a corneal infection poses a challenge to the
revealed fungal elements in 39 cases while 40 cases ophthalmologist because of its tendency to mimic other types
showed fungus on Gram stained smears. Males (54.55%)
of stromal inflammation [5]. Mycotic keratitis should be
were more commonly affected than the females (45.45%).
suspected in every patient with a corneal lesion and should be
The age ranged from 18 to 82 years. Most common age
ruled out promptly to save sight and before commencing
group to be involved was 41-60 years. Predisposing risk
steroids and antibiotics. Use of empiric antifungal therapy is
factors were seen in 34 (77.27% ) cases. Most common
findings on clinical examination were anterior chamber discouraged and a confirmatory diagnosis is recommended
reaction and conjunctival injection seen in all the cases. before institution of therapy[6].
Other common findings were stromal infiltration and The frequency and spectrum of fungi involved varies from
hypopyon seen in 20 (45.45% ) and 18 (40.91% ) cases place to place as several factors like climate, age, sex,
respectively. On histopathological examination the geographical and socioeconomic conditions play a significant
fungus was typed, as aspergillus in 34 cases while no role in modulating the incidence and prevalence of fungal
definite typing was possible in 10 cases. The corneal infections[7,8].
predominant isolate was aspergillus flavus (59.09%) followed Among the important predisposing factors related to corneal
by fusarium (15.91%). Mixed fungal and bacterial infection ulcer are trauma (generally with plant materials), chronic
was seen in 3 (6.82%) cases. ocular surface disease, contact lens usage, ocular surgery,
CONCLUSION: Although culture is the gold standard corneal anesthetics abuse, diabetes mellitus, vitamin
for definitive diagnosis of fungal keratitis, direct deficiency and immunodeficiencies[9,10].
microscopic examination of corneal scrapings or For laboratory diagnosis of mycotic keratitis, demonstration
histomorphological evaluation of biopsies allow a rapid of fungal pathogens on direct microscopy and their isolation
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by culture is essential. Aim of the present study is to Table 1 Slit lamp examination findings in mycotic keratitis
determine the etiological agents, predisposing factors and patients (n=44)
Signs No. of the patients %
important diagnostic tests in keratomycosis in North India.
Feathery infiltrate 05 11.36
SUBJECTS AND METHODS
Satellite lesions 03 6.82
A retrospective analysis of fungal corneal ulcers was done in
Conjunctival injection 44 100
the last ten years (2003-2012). A brief clinical history Immune rings 01 2.27
including the history of trauma, occupation and use of Endophthalmitis 01 2.27
topical/systemic antibiotics/corticosteroids were noted from Epithelial defect 14 31.82
the file records. The corneal tissue received in the pathology Suppuration 04 9.09
department was processed to study the histomorphology. Stromal infiltration 20 45.45
Sections were stained with hematoxylin & eosin. Special Anterior chamber reaction 44 100
stains for fungus, Periodic acid Schiff and Grocott, were Hypopyon 18 40.91
Vascularisation 05 11.36
done. The morphology of the fungal elements was studied
Dry looking ulcer 01 2.27
and the typing was done wherever possible. The corneal
Corneal thinning 12 27.27
scrapings sent to the microbiology department were used to Perforation 10 22.73
prepare a wet mount with 10% potassium hydroxide (KOH).
Also, lactophenol cotton blue staining and Gram staining
were done and fungal elements were examined under the
microscope. Inoculation on Sabourad's dextrose agar and
blood agar plates was done at room temperature. The cultures
were studied by the microbiologist. A correlation of
histopathological diagnosis was done with the fungal culture
report.
RESULTS
Mycotic keratitis was established in 44 cases by a positive
fungal culture. Out of these, 24 were male and 20 were
Figure 1 Slit lamp photograph showing 5.5mm4.5mm fungal
female. The age ranged from 18 to 82 years. Peak incidence
corneal ulcer with dense stromal infiltrates, feathery margins,
of mycotic keratitis was observed in the month of April.
satellite lesions and dense thick immobile hypopyon.
Predisposing risk factors were noted in 34 patients. A prior
history of trauma was seen in 26 cases. Clinical
symptomatology of majority of the patients comprised of
redness, watering, photophobia and ocular pain. History of
topical antibiotic/steroid usage was seen in 08 cases. Use of
contact lenses and prior ocular surgery was not found in any
case. Most common findings on clinical examination were
anterior chamber reaction and conjunctival injection seen in
all the cases (Table 1). Other common findings were stromal
infiltration and hypopyon seen in 20 (45.45% ) and 18
(40.91%) cases respectively (Figures 1, 2). On histopathological
Figure 2 Slit lamp photograph (diffuse) showing fungal corneal
examination septate, slender, branching hyphae were seen in ulcer with resolving dense stromal infiltrates with feathery
34 cases where the fungus was typed as aspergillus (Figures margins.
3, 4) while no definite typing was possible in 10 cases.
Direct microscopic examination of KOH mounts revealed
fungal elements in 39 cases while 40 cases showed fungus on
Gram stained smears. The KOH mount failed to show any
fungal profiles in 05 culture positive cases. The sensitivity of
the KOH mounts and Gram stained smears was 88.64% and
90.91% , respectively. The specificity was 98% each. Cases
showing fungal elements on histopathology/KOH mounts but
with sterile cultures were excluded from the study. Mixed
fungal and bacterial infection was seen in three cases. The
predominant isolate was aspergillus flavus followed by Figure 3 Photomicrograph showing septate slender hyphae in
fusarium (Table 2). a case of mycotic keratitis (H&E, 200).
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Clinicopathologic spectrum of mycotic keratitis

Table 2 Fungal species isolated from corneal ulcer patients (n=44)

Fungal isolate No. of the patients %
Aspergillus flavus 26 59.09
Fusarium 07 15.91
Aspergillus fumigatus 05 11.36
Rhizopus 01 2.27
Curvularia lunata 02 4.54
Alternaria 01 2.27
Figure 4 Fungal elements of aspergillus highlighted on periodic Phaeoacremonium parasiticum 01 2.27
acid Schiff staining (PAS, 200). Penicillium 01 2.27

Table 3 Comparative studies on mycotic keratitis

No. of cases with
Place Author Year Organism 1 Organism 2
fungal isolates
Aspergillus
Sari Shokohi et al[1] 2004-2005 7 Fusarium spp
fumigatus
Aspergillus
Rajshahi Akter et al[14] 2006-2007 33 Aspergillus flavus
fumigatus
Massachusetts Jurkunas et al[20] 2004-2007 46 Fusarium spp Candida albicans
Melbourne Bhartiya et al[21] 1996-2004 56 Candida albicans Aspergillus fumigatus
Amritsar Arora et al[22] 2009 40 Aspergillus Fusarium
Philadelphia Yildiz et al[23] 1999-2008 76 Fusarium Candida
[24]
Bangalore Anusuya et al 2009-2011 38 Fusarium spp Aspergillus fumigatus
New Delhi Chowdhary et al[11] 1999-2001 191 Aspergillus spp Curvularia spp
Varanasi Tilak et al[15] 2004-2008 41 Aspergillus flavus Fusarium solani
Present study 2003-2012 44 Aspergillus flavus Fusarium

DISCUSSION seen in 08 (18.18%) cases. Use of contact lenses by wearers

Mycotic keratitis responsible for corneal blindness is the practicing poor hygiene is another factor seen mostly in the
second most common cause of blindness in the developing developed world. Our study had no case with contact lens
countries [11]. During many years in the past much emphasis wear which is in congruence with some studies[3,15].
was given to the trachoma diagnosis and treatment. It is only On clinical examination mycotic ulcer has a central
in the recent years that there has been a paradigm shift and greyish-white elevated discoid ulcer with irregular
stress is being given to fungal keratitis. fragmented, undermined edges, with a yellow line of
Males were affected more commonly than the females, which demarcation. Satellite infiltrates are seen around the edge of
is usually the case [11,12]. However, a higher incidence amongst the ulcer. Satellite lesions indicate extension of the fungus.
the females is reported in some studies [13]. The disease was Small sized ulcers may be associated with hypopyon [4].
more common in the age group of 41-60 years which is in Hypopyon was seen in 18 (40.90%) and satellite lesions in 03
contrast to the observations by Chowdhary and Singh [11] (6.18% ) cases out of total 44 cases in the present study.
where preponderance was seen between 31-40 years of age. Fungal endophthalmitis was seen in one case which is usually
The possible reason could be that our hospital caters to more infrequent and results in poor visual outcomes [16]. Clinical
patients who are from the rural background. severity of corneal ulcer at presentation is a predictor of
The major risk factors implicated in causation of fungal worst outcome[17].
corneal ulcers include occupational farming, a history of A wide variety of fungi have been known to cause keratitis.
trauma, use of topical/systemic antibiotics or steroids, The commonly implicated ones are aspergillus and
immunocompromised states and diabetes mellitus [11,14]. The fusarium [ 5, 11,14 ,18-22] . Various studies of mycotic keratitis
most common predisposing factor found in our study was implicate aspergillus species as the commonest incriminant
trauma to the cornea seen in 26 (59.09%) cases. The agents (Table 3) [1,11,14,15,22]. The present study showed a much wider
responsible for trauma were primarily thorns, tree branches spectrum of fungi implicated in causation of fungal keratitis.
and husk. Other studies have also found trauma to be the Out of our 44 cases of mycotic keratitis the predominant
commonest predisposing factor in the spectrum of fungal fungal isolate was aspergillus flavus followed by fusarium.
keratitis. The percentage of corneal trauma has been reported Both aspergillus fumigatus and aspergillus flavus have been
to be as high as 42% by Chowdhary and Singh [11]. Injudicious almost equally implicated as the causative agents in mycotic
use of topical antibiotics/steroids as an implicating factor was corneal ulcers. Curvularia lunata was seen in 2 cases which is
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8629 8629-82210956 ijopress
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8 Lin CC, Lalitha P, Srinivasan M, Prajna NV, McLeod SD, Acharya NR,
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In severe and deep mycotic keratitis, freshly prepared 2007;35(1):44-50
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12 Saha S, Banerjee D, Khetan A, Sengupta J. Epidemiological profile of
confirmed on culture report, fortified cefazolin drops (5%)
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16 Chhablani J. Fungal endophthalmitis.
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17 Prajna NV, Krishnan T, Mascarenhas J, Srinivasan M, Oldenburg CE,
of blindness. They need to be suspected clinically followed
Toutain-Kidd CM, Sy A, McLeod SD, Zegans ME, Acharya NR, Lietman
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ACKNOWLEDGEMENTS LMA, De Castro RS, E Faria E Sousa SJ, Rocha EM. Epidemiologic aspects
Conflicts of Interest: Punia RS, None; Kundu R, None; and clinical outcome of fungal keratitis in southeastern Brazil.
Chander J, None; Arya SK, None; Handa U, None; 2009;19(3):355-361
Mohan H, None. 19 Wang L, Sun S, Jing Y, Han L, Zhang H, Yue J. Spectrum of fungal
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