Mycotic Keratitis Due to Aspergillus nomius

Abstract

We report the first known case of fungal keratitis caused by Aspergillus nomius. Ocular injury was known as a predisposing factor. The patient was treated with natamycin and econazole eye drops, itraconazole eye ointment, and oral ketoconazole. A therapeutic penetrating keratoplasty was performed 16 days after presentation. A sequence-based approach was used to assign the isolate to a species. CASE REPORTA 64-year-old woman with no significant ophthalmic or systemic history presented with a history of pain, redness, and defective vision of the right eye of 4 days' duration following a minor trauma sustained by mud splashing into the eye. She had been treated elsewhere earlier, and her medications consisted of the use of tobramycin, phenylephrine, natamycin, and moxifloxacin eye drops for 1 day.On examination, her uncorrected visual acuity was less than 20/800 (Ͻ1/60) in the right eye. Slit lamp examination of the right eye was significant for an area of infiltration (6.2 to 7.5 mm) involving the central cornea and extending toward the limbus temporally and superiorly. The infiltrate involved all the layers of the stroma, and there was a dense endothelial plaque. A hypopyon of 1 mm was present. Scrapings obtained from the corneal infiltrate were stained (Gram's stain and 10% KOH) and plated on 5% sheep blood agar, chocolate agar, and potato dextrose agar. Both the Gram stain and the KOH mounts were positive for fungal filaments, and the cultures subsequently grew a fungus which was initially identified as a member of Aspergillus section Flavi.Given the severity of the infection, the patient was admitted to the hospital, and intensive topical antifungal therapy was initiated. Natamycin (5%) and econazole (2%) eye drops were started on a half-hourly basis, while itraconazole (1%) eye ointment was applied three times a day. This was supplemented with cycloplegics (homatropine) and medication for the relief of pain. Oral antifungal medication in the form of tablets (200 mg ketoconazole twice a day) was also given.In spite of intensive therapy, the infiltrate continued to progress with thinning and melting of the cornea. Doxycycline tablets were administered to decrease the collagenolytic activity, and amphotericin B (50 g/ml) eye drops were also added to the medical regimen, but the infiltrate continued to progress to involve the entire cornea with descemetocele formation and finally perforation. A therapeutic penetrating keratoplasty was performed 16 days after presentation. Scleral extension was noted intraoperatively at the superior limbus. The corneal button removed at the time of surgery was also positive for a heavy growth of Aspergillus. Postoperatively the same medical regimen was continued in a tapering fashion, and the patient was discharged on the 10th postoperative day. After an interval of 35 days postoperatively, she once again presented with an area of infiltration at 11 o'clock of the superior sclera; this was treated successfully medically, and the infiltrate healed in a week. She was asked to contin...

Misidentification of Aspergillus nomius and Aspergillus tamarii as Aspergillus flavus: Characterization by Internal Transcribed Spacer, β-Tubulin, and Calmodulin Gene Sequencing, Metabolic Fingerprinting, and Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry

“…It was difficult for clinical microbiology laboratories to identify rarely found molds as causes of various infections. The more widespread use of ITS and other gene sequencing has enabled clinical microbiology laboratories to con- fidently identify molds that are rarely found in patients after preliminary morphological examination (13)(14)(15)(16)(17)(18)29). In addition, novel fungal species associated with clinical infections have been discovered (9)(10)(11).…”

“…These results were also in line with those of metabolic fingerprinting, in which the A. flavus, A. nomius, and A. tamarii strains were separated into three clusters based on UHPLC MS analysis. Although A. flavus, A. nomius, and A. tamarii may (Table 2) (13)(14)(15)(16)(17)(18)29). Among the 15 strains with methods of laboratory diagnosis described in detail, all of them required molecular technologies (sequencing in 14 and high-performance liquid chromatography analysis of metabolites in 1) for identification.…”

“…In addition, it has led to the discovery of novel pathogenic fungal species (11,12). In the last decade, a number of case reports, with the help of ITS, ␤-tubulin, and calmodulin gene sequencing, have identified Aspergillus nomius and Aspergillus tamarii as causes of human infections (13)(14)(15)(16)(17)(18). Since A. nomius and A. tamarii are yellow and are also under the same Aspergillus section Flavi as A. flavus, we hypothesize that they can be easily misidentified as A. flavus and that a proportion of fungus isolates reported as A. flavus might be A. nomius or A. tamarii.…”

Identification ofAspergillusspecies in Central Europe able to produce G-type aflatoxins

“…It was also identified in house dust samples from Mexico [43]. This species has also been found to be able to cause human infections including onychomycosis in Italy [44], keratitis in India [22], invasive aspergillosis, cavitary and fibrosing pulmonary and pleural aspergillosis in Hong Kong [39] and breakthrough pneumonia in Italy [4]. Besides, it was also identified as the causative agent of stonebrood disease in honeybees in Great Britain [13].…”

Biological Activities of the Alkaloid Quinazoline Extracted from Aspergillus nomius

“…Aspergillus nomius is known to be human pathogenic as it was isolated form keratitis on Coimbatore India by Manikandan et al (2009). Despite its potential as an aflatoxins producer, according to Frisvad et al (2004), Aspergillus nomius showed pharmaceutical importance to produce aspergillic acid which is most commonly known as an antibiotic and antifungal agent, pseurotin which is known to have antiparasitic and anticancer activities.…”