Successful Treatment ofFusarium Keratitis with Cornea Transplantation and Topical and Systemic Voriconazole

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Abstract
Case report. A previously healthy male, aged 23 years, presented to our hospital (Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands) with severe and very painful keratitis of the right eye, which had developed during 1 week. He used daily-wear, disposable contact lenses and had been diving in the Port of Willemstad, Curacao. The local ophthalmologist in Curacao had started treatment with ciprofloxacin, amphotericin B, acyclovir, and atropine 4 days before the patient presented to our hospital. The visual acuity of the affected eye was limited to hand movements at 1 m. The conjunctiva showed severe injection, and a corneal ulcer with an infiltrate measuring 4.5–6.5 mm was present, as was a hypopyon in the anterior chamber of the eye. Direct staining of corneal scrapings showed mycelia, and antifungal treatment was started with a topical amphotericin B 0.5% preparation applied hourly and systemic itraconazole at a dosage of 200 mg administered daily. However, despite this therapy, the infiltrate increased in size and approached the limbal area. Culture of the corneal scrapings grewFusarium solani with an elevated MIC for amphotericin B (4 µg/mL) and itraconazole (>16 µg/mL) but a low MIC for voriconazole (2 µg/mL). The MIC was determined using the microdilution technique according to the NCCLS M38-A guidelines [1]. However, the minimal fungicidal concentration, defined as the lowest concentration at which ⩾99.5% of the inoculum is killed, was >16 µg/mL for voriconazole [2]. Penetrating keratoplasty and peripheral iridectomy were performed on day 8 of hospitalization, and medical treatment was changed to intravenous voriconazole (6 mg/kg b.i.d. on the first day, followed by 4 mg/kg b.i.d. on successive days). Because of the rapid progression of the infection, the intravenous formulation of voriconazole was applied topically (as a 1% voriconazole eyedrop solution) at hourly intervals to obtain high drug levels at the site of infection.