Successful treatment of ocular invasive mould infection (fusariosis) with the new antifungal agent voriconazole

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Abstract
In November 1998, a 16 year old girl was transferred to the university eye hospital in Duesseldorf with a severe ulcerative hypopyon keratitis in the left eye, from which she had been suffering for 3 months after swimming in a lake in Italy. Smears, scrapings, and serology gave no hint of the aetiology. Despite intensive topical antibacterial, anti-acanthamoebal, antifungal, and antiherpetic therapy, as well as cryoapplication, her clinical situation had deteriorated continuously before admission to our hospital. As an optical rehabilitation was unlikely, owing to the severely infiltrated cornea, a perforating keratoplasty was performed. Postoperatively, the patient was given systemic as well as topical antibiotics. The first 3 days postoperatively were inconspicuous, but from the sixth day on a hypopyon could again be seen. The hypopyon progressed and we could identify, by ultrasound biomicroscopy the focus at the remaining recipient cornea. We removed this focus which was highly suspected of being a fungal colony and sent it to the microbiology department (an attempt to culture bacteria or fungi failed). Antifungal therapy with systemic fluconazole (200 mg/day intravenously) and topical amphotericin B (0.3% every hour) were started, but the clinical picture still deteriorated. At that time a filamentous fungus was diagnosed histopathologically in the excised corneal button (Fig 1). Because of the morphological similarities betweenAspergillus,Fusarium, andPseudallescheria boydii on histology these potent causes of keratitis could not be differentiated by this technique alone. Immunohistochemical examination of mycelia containing tissue sections with a panel of specific antifungal antibodies, all Grocott methenamine silver positive hyphae were identified asFusarium species because a strong and uniform reactivity was obtained only with a heterologously absorbed polyclonal antibody raised towards somatic antigens ofFusarium solani.6

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