Scedosporium Prolificans: The First Case-Report In A Tertiary Hospital In Southern Brazil And A Successful Outcome In A Challenging Keratitis.

S. prolificans (also known as Lomentospora prolificans), an opportunistic and filamentous fungus, is a rarely described ocular entity that is difficult to identify, to heal and is a truly emerging pathogen with rare but severe ophthalmic consequences and several areas of uncertainty still exist regarding treatment. 

Successful recovery from infection is difficult due to high rates of intrinsic resistance to antifungals. Here in we report the first and a challenging case of S.prolificans keratitis in a tertiary care hospital in southern Brazil.

1. Ophthalmology department, Federal University of Paraná, Curitiba, Brazil

A 59-year-old male patient was referred to our hospital due to a corneal ulcer. His ophthalmology record described phacoemulsification in his right eye (OD) two months before and appearance of pain and a leucoma one month after the surgery. Treatment was started at his city of origin with topical antibiotics and poor clinical response.

The patient presented to us using Vigamox® and Hyabak® hourly. His best corrected visual acuity (BCVA) was hand motion in OD and 20/40 in the left eye (OS). Slit lamp examination showed a corneal ulcer of 10x10 millimeters (fig.1) with an endothelial fibrin plaque and no significant stromal thinning in OD and normal in OS. Endophthalmitis was ruled out using ultrasound. Opted to cease use of  antibiotics for 24 hours to collect a corneal scrape. Topical amphotericin B was started hourly and an intracameral injection was performed using 5 micrograms per 0,1 milliliter(mm) concentration. Microbiology test results grew Scedosporium prolificans, never before isolated in our hospital (fig.2a and 2b) using Sabouraud and Chocolate Agar growth mediums.

Twenty-five days later, the ulcer measured 1x1mm, resolving in subsequent days. Topical antifungal was suspended after 8 months. One year after the onset, penetrating keratoplasty was performed in OD (Fig. 3) due to a cicatricial leucoma. After two months, he presented a satisfactory postoperative and BCDVA of 20/160 in OD, in process of improvement with the management of keratoplasty-induced astigmatism.

In the presence of corneal keratitis with insidious presentation and difficult management, fungal infection must be considered. S. prolificans is a rare and multi resistant fungus mostly associated with systemic infections, with few records in medical literature of ophthalmological involvement. The treatment by a route of administration that delivers high concentration on the infection site seems to have been responsible for the success in this case, even though the chosen medication is not the drug of choice for this pathogen.