Successful Treatment of Paecilomyces lilacinus Keratitis With Oral Posaconazole

Abstract

Purpose To report a case of successful medical treatment with oral posaconazole in refractory fungal keratitis caused by Paecilomyces lilacinus. Methods Case report. Results A 57-year-old male soft contact lens wearer presented with irritation, pain, photophobia and reduced vision. Slit-lamp examination showed a large corneal epithelial defect with a peripheral infiltrate. The patient did not improve on fortified topical antibiotics. Following diagnosis of Paecilomyces lilacinus fungal keratitis, oral voriconazole and topical antifungal therapy were started. Despite antifungal therapy, progressive disease required therapeutic penetrating keratoplasty (PKP). Postoperatively, due to clinical signs of recurrence and in vivo confocal microscopy (IVCM) findings of presumed hyphae in the cornea, intracameral miconazole was injected and oral posaconazole was started. The patient improved and demonstrated no hyphae 6 weeks after starting posaconazole. When posaconazole was stopped the cornea remained clear with excellent acuity. However, due to acute graft rejection 2 months after stopping posaconazole, keratoprosthesis was implanted, with no evidence of infection at surgery or during 3.5 years follow-up. Conclusion To our knowledge, this is the first report on the use of oral posaconazole for Paecilomyces keratitis. Posaconazole might be indicated in the treatment of refractory Paecilomyces keratitis resistant to conventional therapy.

Fungal keratitis: study of increasing trend and common determinants

“…[ 12 ], Acremonium spp. [ 13 ], Cryptococcus albidus [ 14 ]), Pythium insidiosum [ 15 ], Beauveria bassiana [ 16 ], Paecilomyces [ 17 ], Cunninghamella spinosum [ 18 ], Scedosporium apiospermum [ 19 ]), Rhodotorula mucilaginosa [ 20 ], Cylindrocarpon lichenicola [ 21 ], Cladorrhinum bulbillosum [ 22 ]. Lophotrichus species were isolated from the necrotic corneal sample complicating fungal keratitis after dog paw traumatic injury [ 11 ].…”

Posaconazole in the treatment of refractoryPurpureocillium lilacinum(formerPaecilomyces lilacinus) keratitis: the salvation when nothing works

“…The most described adverse effects of posaconazole in the literature are gastrointestinal complaints, abnormal liver function tests and pleural effusion 13 18. Our patient manifested an increase of serum creatinine levels and hypokalaemia, which resolved after withdrawal of posaconazole.…”

“…To the best of our knowledge, there is only one report on the use of oral posaconazole for P. lilacinus keratitis. Although in that report the patient was submitted to a keratoprosthesis implantation 2 months after stopping oral posaconazole due to graft rejection, he remained with no evidence of infection after 3,5 years 13…”

“…Posaconazole, a triazole antifungal, has shown to be effective in the treatment of P. lilacinus infection, in a murine model 12. In addition, it has recently been used in a case of relapsing keratitis due to P. lilacinus with good response 13…”

Retrospective case-series of Paecilomyces lilacinus ocular mycoses in Queensland, Australia

“…In vitro evidence also exists for the efficacy for posaconazole and ravuconazole [ 7 ], and one of the patients in the series did receive oral posaconazole, due to deranged liver functions as a result of oral voriconazole therapy. A recent case report also highlights the clinical efficacy of posaconazole in paecilomyces infection [ 30 ]. Voriconazole, a triazole antifungal, which inhibits fungal cytochrome P-450 mediated 14 α-lanosterol demethylation, a necessary step in ergosterol synthesis.…”