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Keratitis due to Auerswaldia lignicola in a 32-year-old Indian male carpenter is described. At presentation, the patient reported persistent pain and tearing (left eye) in spite of topical antimicrobial therapy for more than 3 weeks. Clinically, mycotic keratitis was suspected, and direct microscopy of corneal scrapings stained by lactophenol cotton blue and Gram stains revealed broad septate hyphae. Intensive topical antifungal therapy was then given for 15 days. The keratitis continued to progress, necessitating therapeutic penetrating keratoplasty. Following the keratoplasty, there was rapid reduction in inflammation and gradual quietening of the eye. Brown-black fungal colonies resembling Lasiodiplodia theobromae were isolated from corneal scrape and corneal button (post-surgery) material on Sabouraud glucose-neopeptone agar; however, sporulation did not occur, so the morphological identification could not be confirmed. Sequence analysis of the 18S rRNA region of extracted fungal genomic DNA yielded an identification of A. lignicola Ariyawansa, J.K. Liu & K.D. Hyde; the sequence data have been deposited in GenBank (A. lignicola strain DK/V4, accession number KC866317.1). Medical management of keratitis due to such rarely reported fungal species may be difficult, necessitating surgical procedures.

Purpose: To document transcriptional activation (expression) of key aflatoxin biosynthetic pathway genes in corneal isolates of Aspergillus flavus., Methods: The expression of certain regulatory (aflatoxin regulatory [aflR] and aflatoxin J [aflJ]) and structural (polyketide synthase acetate [pksA] and norsolonic acid-1 [nor-1]) genes in four corneal A. flavus isolates was evaluated by reverse transcription PCR. The aflatoxin-producing potential of each strain was determined by thin-layer chromatography and quantified by spectrophotometry. Four environmental isolates were used for comparison. The mean expression levels of these genes were compared in the corneal and environmental A. flavus isolates. In addition, the mean expression levels were also correlated with the aflatoxin production levels., Results: All isolates expressed aflJ, nor-1, and pksA, while all but one expressed aflR. Overall, significantly higher mean expression levels occurred in aflatoxigenic than in non-aflatoxigenic corneal isolates. A significant positive correlation was noted between the mean expression level of aflR and the quantum of aflatoxin production by the corneal isolates. Essentially similar patterns of expression of these genes were noted in four environmental A. flavus isolates used for comparison., Conclusions: For the first time, isolates of A. flavus from human keratitis patients have been shown to express regulatory and structural aflatoxin biosynthetic pathway genes. Further studies are needed to clarify the precise influence of the corneal microenvironment on expression of these genes and aflatoxin production by A. flavus infecting the cornea.

Bilateral keratitis usually occurs in predisposed individuals such as contact lens wearers, those suffering from malnutrition and immunodeficiency or patients undergoing bilateral refractive corneal surgery. We report a 30-year-old man without any obvious predisposing factors who presented with complaints of pain and decreased vision in both eyes. Examination revealed corneal ulcers in both eyes, which on microbiological culture grew Pseudomonas aeruginosa. The patient underwent a therapeutic keratoplasty in the right eye while the left eye was managed medically. Bilateral Pseudomonas keratitis can develop in the absence of any obvious predisposing factors.

Purpose: To compare the clinical efficacy of itraconazole 1% eyedrops with a standard therapy regimen (natamycin 5% eyedrops) for topical monotherapy of fungal keratitis., Methods: Patients presenting with suspected uniocular microbial keratitis over a period of 12 months (January to December 2002) underwent detailed clinical examination and microbiological investigation. One hundred consecutive patients with direct smear- and/or culture-proven fungal keratitis were enrolled in the study after obtaining informed consent. The ulcers were categorized as severe or nonsevere. The first 50 consecutive patients received primary therapy with topical natamycin hourly, and the next 50 consecutive patients received topical itraconazole hourly. The primary efficacy criteria were the physician's judgment of clinical success, cure rate, and the rate of treatment failure., Results: The diagnosis of fungal keratitis was established by positive microscopy and culture findings in 88 patients and by positive microscopy alone in 12 patients. Species of Fusarium, Aspergillus, and Curvularia were the principal isolates. Thirty-six (72%) of 50 patients (28 of 37 with nonsevere keratitis and 8 of 13 with severe keratitis) showed a favorable response to primary natamycin therapy (mean duration, 20.5 days), while 30 (60%) of 150 patients (25 of 38 with nonsevere keratitis and 5 of 12 with severe keratitis) exhibited a favorable response to primary itraconazole therapy (mean duration, 23.1 days). In keratitis due to Fusarium spp, 19 (79%) of 24 patients showed a favorable response to natamycin, which was significantly greater than the 8 (44%) of 18 patients who showed a favorable response to itraconazole (P < 0.02). However, no such difference was evident in keratitis due to Aspergillus spp or Curvularia spp; in keratitis due to Aspergillus spp, favorable responses were noted in 6 (54.5%) of 11 patients receiving natamycin and 5 (50%) of 10 patients receiving itraconazole, while in keratitis due to Curvurlaria spp, such responses occurred in both patients receiving natamycin and in 8 (89%) of 9 patients receiving itraconazole. Both antifungal formulations were generally well tolerated with no obvious adverse effects., Conclusions: Topical natamycin should continue to be considered as the treatment of choice for filamentous fungal keratitis; when natamycin is unavailable, topical itraconazole therapy could be used, particularly if the infections are due to Aspergillus or Curvularia spp.

Abstract Aim: To study the clinical features of pneumococcal keratitis and response to ciprofloxacin therapy. Methods: A retrospective analysis was undertaken of 58 patients with culture-proven pneumococcal keratitis seen over a period of 2 years. Results: Pneumococcal keratitis accounted for 33.3% of bacterial keratitis. Most cases presented with non-severe keratitis (77.5%). Co-existing sac pathology was more frequent in pneumococcal ulcers as compared to non-pneumococcal bacterial ulcers (50%vs 9%, P < 0.001 ). Characteristic clinical features enabling an accurate clinical diagnosis were found in 27.5% and lanceolate diplococci on Gram's stain were identified in 76% of cases. In vitro testing showed a high susceptibility to cephazolin and ciprofloxacin. All patients received ciprofloxacin as first-line therapy. Eighty per cent responded well with complete healing of the ulcer. A second drug was required in 8.5%. Conclusion: Ciprofloxacin therapy can be effective in the treatment of pneumococcal keratitis. [ABSTRACT FROM AUTHOR]