Unusual Pediatric Keratitis: Trichophyton Rubrum And The Road To Therapeutic Keratoplasty

To report a rare case of severe fungal keratitis in an immunocompetent child, secondary to Trichophyton rubrum onychomycosis, with rapid progression despite maximal medical therapy and requiring urgent therapeutic keratoplasty.

A 10-year-old girl presented with a one-month history of painful red eye and profound visual loss in the left eye. 

Visual acuity was counting fingers at 1 meter ; IOP was normal.

Slit-lamp findings showed a round paracentral corneal abscess, diffuse stromal edema, and a hypopyon, without conjunctival invasion or peripheral corneal neovascularization.

Corneal scraping was negative, but fungal culture from a concurrent fingernail onychomycosis identified Trichophyton rubrum, suggesting probable self-inoculation.

The patient was hospitalized and received intensive antifungal therapy: fortified topical voriconazole and amphotericin B, along with topical levofloxacin and antiseptics. Systemic treatment included IV voriconazole and amoxicillin–clavulanic acid.

Metronidazole and oral terbinafine were added on day 3, and natamycin was introduced on day 9.

Despite full medical therapy (natamycin, amphotericin B, and voriconazole), the abscess enlarged with persistent ocular pain. An urgent therapeutic penetrating keratoplasty was performed, combined with anterior chamber washout using amphotericin B and microbiological corneal sampling.

At 1-year follow-up, visual acuity improved to 2/10, with a clear graft and sutures in place.

Fungal keratitis caused by Trichophyton rubrum is extremely rare in children. This case highlights the importance of early suspicion, aggressive antifungal therapy, and timely surgical intervention when medical treatment fails.