Treatment With Intrastromal and Intracameral Voriconazole in 2 Eyes With Lasiodiplodia theobromae Keratitis

Abstract

To report the clinical presentation and the role of intrastromal and intracameral voriconazole injection in the management of rare cases of fungal keratitis caused by Lasiodiplodia theobromae.Two eyes of 2 patients with Lasiodiplodia keratitis unresponsive to topical and oral antifungal medications were included in this study. Diagnosis of Lasiodiplodia keratitis was confirmed by microbiological analysis, including culture-based (case 1 and 2) and DNA sequencing techniques (case 2 only).The first patient presented with multiple satellite lesions and one of these infiltrates spread deeply into the cornea, forming a stromal abscess. Another patient had a large full-thickness corneal infiltrates with several fungal balls in the anterior chamber, requiring a limbus-to-limbus therapeutic penetrating keratoplasty. Despite aggressive topical therapy, the stromal abscess continued to worsen in the first case and recurrent keratitis was observed postoperatively in the second case. Voriconazole 50 μg/0.1 mL was administered intracamerally and intrastromally around the fungal abscess as adjuncts to topical antimycotics in the first case. The second patient who needed therapeutic keratoplasty was treated with an intracameral injection of 50 μg/0.1 mL voriconazole at the end of surgery. Postoperatively, 100 μg/0.1 mL voriconazole was also injected intracamerally after the recurrence of infection was noted in the graft. Reinjections were given 48 hours apart in both cases. After the injections, all corneal and anterior chamber lesions were reduced in size and density and completely resolved within 4 weeks.Intrastromal and intracameral voriconazole injections may offer safe and effective treatment options for L theobromae keratitis.

Molecular and Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry-Based Characterization of Clinically Significant Melanized Fungi in India

“…Also, in the present study the first case of keratitis due to R. percutanea was observed. Further, L. parva, which had not been previously reported from human infections, was found to be the etiologic agent of postoperative wound infection in a renal transplant patient, although other species, such as L. theobromae, detected as agents of keratitis in this study, have previously been documented as agents of keratitis and subcutaneous infections (22)(23)(24)(25). Interestingly, fungal osteomyelitis of the foot due to C. bantiana and Corynespora spp.…”

Successful Treatment of Lasiodiplodia theobromae Keratitis – Assessing the Role of Voriconazole

“…Clinical response from medical therapy alone has been reported in 3 cases with the use of topical natamycin alone [3], and in 1 case combined with topical amphotericin B [4]. Treatment outcomes using azoles were poor, with disease progression to endophthalmitis and panophthalmitis [5, 6, 7, 8]. Surgical treatment by keratoplasty was often required [2, 8].…”

“…Treatment outcomes using azoles were poor, with disease progression to endophthalmitis and panophthalmitis [5, 6, 7, 8]. Surgical treatment by keratoplasty was often required [2, 8]. However, all cases were complicated by recurrence of infection or graft failure.…”

“…[9] Use of voriconazole has only been reported in 3 cases. All 3 cases showed a poor response to topical voriconazole, with 2 cases requiring keratoplasty and 1 case requiring repeated injections of intracameral voriconazole [2, 8]. …”

Lasiodiplodia species fungal osteomyelitis in a multiple myeloma patient

“…The optimal antifungal treatment is not known for this species. Based on prior case reports and prior antifungal susceptibility testing, voriconazole is expected to appropriately treat this infection , and the patient was continued on oral voriconazole alone after 14 days of liposomal amphotericin B. While Lasiodiplodia has been reported in the literature as relatively easy to grow , our fungal culture was without growth despite the abundance of organisms observed on histopathology.…”