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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 57  |  Issue : 2  |  Page : 167-169

Isolated anterior-chamber fungal flocculosus in a healthy child with seeding through the trabecular meshwork


Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India

Date of Web Publication10-Sep-2019

Correspondence Address:
Dr. Manjula Jayakumar
Dr. Agarwal's Eye Hospital and Eye Research Centre, No_19, Cathedral Road, Chennai - 600 086, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_36_19

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  Abstract 


We report a case of isolated anterior-chamber (AC) fungal hyphae in a healthy child following injury with a broomstick with no evidence of obvious intraocular penetration, a rare presentation of isolated traumatic AC mycoses. In our case, although there was no obvious intraocular penetration, a broom bristle could have injured the trabecular meshwork acting as a conduit for the seeding of the fungal growth. Ours is a peculiar case of seeding through the trabecular meshwork so far not cited in literature.

Keywords: Anterior-chamber flocculosus, Fusarium, no intraocular penetration, trabecular meshwork, trauma


How to cite this article:
Jayakumar M, Parthasarathy A. Isolated anterior-chamber fungal flocculosus in a healthy child with seeding through the trabecular meshwork. TNOA J Ophthalmic Sci Res 2019;57:167-9

How to cite this URL:
Jayakumar M, Parthasarathy A. Isolated anterior-chamber fungal flocculosus in a healthy child with seeding through the trabecular meshwork. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2019 Sep 22];57:167-9. Available from: http://www.tnoajosr.com/text.asp?2019/57/2/167/266390




  Introduction Top


Fungi are opportunistic pathogens in the eye, and they rarely infect healthy, intact ocular tissue. Keratitis is the most frequent presentation.[1] The common route of entry of the pathogen is external as a result of breach in the epithelium.[2] Intraocular anterior-chamber (AC) fungal mycoses in a healthy child as an isolated presentation following trauma is very rare when there is no obvious penetration of the foreign body into the AC.


  Case Report Top


A 10-year-old healthy boy presented to our outpatient department with redness and a white fluffy spot inside his left eye following penetrating injury with a broomstick which was of 4 days duration. On examination, the best-corrected visual acuity in the right eye was 6/6, N6 and in the left eye was 6/9, N6. Slit lamp examination in the right eye was unremarkable and that of the left eye showed a small conjunctival tear of about 2 mm size, 4 mm inferior to the limbus at 7 o'clock position with localized congestion and inflammation along the entire inferior limbus. Cornea was clear. AC showed cells of 1+ grade and flare of 2+ grade, and there was flocculent white matter deposited inferiorly [Figure 1]. Lens and vitreous were clear, and fundus was within normal limits in both the eyes. Intraocular pressure measured was 16 mmHg in both eyes. Ultrasound biomicroscopy (UBM) performed was inconclusive; both superior and inferior angles were similar. Following this, the foreign body in the subconjunctival space was removed with a nontoothed forceps and sent for smear and culture. Initial smear on KOH mount showed the presence of fungal filaments based on which the patient was started on topical natamycin 5% hourly, moxifloxacin 0.3% 2 hourly, and tablet fluconazole 150 mg ½ tablet twice daily along with cyclopentolate 0.5% twice a day for symptomatic relief. Further, culture done on Sabouraud dextrose agar was suggestive of Fusarium species. Smear done with the growth from the culture, on KOH mount and lactophenol cotton blue staining, revealed the presence of septate hyphae with macroconidia confirmative of Fusarium species [Figure 2]. The patient was continued on the same medication and was closely followed up. On the 3rd day of starting of antifungals, there was decrease in the AC reaction and the amount of flocculent matter in the AC. At this visit, gonioscopy done showed small peripheral anterior synechiae with streak of blood in the inferior angle without any foreign body present in the angle. The rest of the angle and the angle of the other eye were within normal limits. On a week later of follow-up, there was almost complete clearance of the flocculent matter from AC [Figure 3] and the patient was symptomatically better. Following near-complete resolution of the AC hyphae matter, fluorometholone eye drop 0.1% 4 times a day was started in a tapering fashion to decrease surface inflammation, natamycin eye drop was tapered, and oral fluconazole was stopped after 10 days. The patient completely recovered from the intraocular fungal infection with full recovery of vision.
Figure 1: (a) Anterior-chamber hyphae (flocculosus) along with congestion and chemosis of inferior conjunctiva, (b) broomstick foreign body removed with nontoothed forceps, (c) gonioscopy showing a small peripheral anterior synechiae of the inferior angle represented by arrow, (d) ultrasound biomicroscopy showing no evidence of intraocular penetration of foreign body

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Figure 2: (a) KOH mount showing fungal hyphae, (b) lactophenol cotton blue stain showing macroconidia suggestive of Fusarium species, (c) Sabouraud dextrose agar showing growth of Fusarium species

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Figure 3: One-week posttreatment photograph showing near-complete resolution of the anterior-chamber fungal hyphae

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  Discussion Top


Fusarium is a ubiquitous filamentous fungus. It is a common cause of fungal keratitis and keratitis-associated endophthalmitis.[3],[4] This child gave a history of broomstick injury, and he was not aware of the foreign body being lodged in the subconjunctival space. He presented to us 4 days later with symptoms. UBM showed no obvious intraocular penetration. Since there was a conjunctival bump seen, we removed the subconjunctival foreign body through the tear. Gonioscopy had revealed blood at the angle with peripheral anterior synechiae, suggestive of trauma and intraocular inflammation. In our case, the bristle from the broomstick could have injured the trabecular meshwork at the time of impact and subsequently got sealed acting as a conduit for the entry of the pathogen into the AC. To our knowledge, this is a very rare mode of transmission of fungus into the eye. This mode of entry of presentation in an isolated AC mycosis is so far not reported in literature. Fungal hyphae growing into AC due to deep stromal keratitis and endothelial abscess following penetrating corneal injury in the absence of an epithelial defect has been reported in literature.[5] An isolated case of iridocyclitis and hypopyon without evidence of vitritis or chorioretinitis secondary to Candida albicans infection has been reported in a child with immunocompromised status.[6] In this case, there was hematogenous seeding of fungus into the ciliary body with extension into the iris and body of the lens manifesting as lenticular abscess. Numerous cases of keratitis and endophthalmitis have been reported in literature due to Fusarium species.[7],[8] An isolated case of fungal hyphae in the AC in a case of anterior uveitis has been reported in a healthy lady 56 days postcataract surgery.[9] In this case, the infection had been inoculated into the eye at the time of cataract surgery. In our case, seeding has happened through the injured trabecular meshwork, which has not been reported in literature so far. Based on the clinical findings along with microbiological evaluation of the foreign body, the child was appropriately treated without the need of an AC tap as a diagnostic tool.[10] It is imperative to identify and treat these patients adequately as a delay results in loss of vision in the eye.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lalitha P, Shapiro BL, Srinivasan M, Prajna NV, Acharya NR, Fothergill AW, et al. Antimicrobial susceptibility of Fusarium, Aspergillus, and other filamentous fungi isolated from keratitis. Arch Ophthalmol 2007;125:789-93.  Back to cited text no. 1
    
2.
Klotz SA, Penn CC, Negvesky GJ, Butrus SI. Fungal and parasitic infections of the eye. Clin Microbiol Rev 2000;13:662-85.  Back to cited text no. 2
    
3.
Dursun D, Fernandez V, Miller D, Alfonso EC. Advanced Fusarium keratitis progressing to endophthalmitis. Cornea 2003;22:300-3.  Back to cited text no. 3
    
4.
Wykoff CC, Flynn HW Jr., Miller D, Scott IU, Alfonso EC. Exogenous fungal endophthalmitis: Microbiology and clinical outcomes. Ophthalmology 2008;115:1501-7, 1507.e1-2.  Back to cited text no. 4
    
5.
Cho KJ, Kim MS. Fungal hyphae growing into anterior chamber from cornea. Can J Ophthalmol 2014;49:e151-4.  Back to cited text no. 5
    
6.
Monshizadeh R, Sands RE, Lara WC, Driebe W. Isolated anterior uveitis as the initial sign of systemic candidemia. Arch Ophthalmol 2003;121:137-8.  Back to cited text no. 6
    
7.
Louie T, el Baba F, Shulman M, Jimenez-Lucho V. Endogenous endophthalmitis due to Fusarium: Case report and review. Clin Infect Dis 1994;18:585-8.  Back to cited text no. 7
    
8.
Aggermann T, Haas P, Krepler K, Binder S, Hochwarter A. Fusarium endophthalmitis following refractive lens exchange for correction of high myopia. J Cataract Refract Surg 2009;35:1468-70.  Back to cited text no. 8
    
9.
Deshmukh S, Das D, Medhi J, Bhattacharjee H, Gupta K, Bhola P. Fungal hyphae in the anterior chamber in a case of anterior uveitis: A case report. Adv Ophthalmol Vis Syst 2018;8:231-2.  Back to cited text no. 9
    
10.
Sridhar MS, Sharma S, Gopinathan U, Rao GN. Anterior chamber tap: Diagnostic and therapeutic indications in the management of ocular infections. Cornea 2002;21:718-22.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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