Purpureocillium lilacinum keratitis in a methamphetamine user: Case report

Abstract

Purpureocillium lilacinum (PL) is an infrequent cause of fungal keratitis. Treatment of PL keratitis is complicated by delayed diagnosis, resistance to topical antifungal treatments, and the frequent need for surgical intervention. We report a case of PL keratitis in a patient with a significant history of methamphetamine use who initially presented with a persistent corneal epithelial defect in the right eye and associated exuberant intraocular inflammation as evidenced by a hemorrhagic hypopyon. Despite an extended treatment course with multiple antimicrobial agents, including topical and systemic voriconazole, the patient ultimately underwent penetrating keratoplasty for corneal perforation. Our case represents the first documented instance of PL keratitis in a methamphetamine user, highlighting their increased vulnerability to infectious, including fungal, keratitis. It also demonstrates the challenging and often protracted clinical course of PL keratitis, which often requires both aggressive medical and surgical interventions.

Keywords: Corneal perforation; Purpureocillium lilacinum keratitis; fungal keratitis.

Figure 1

(a) Photograph of the patient’s right eye upon presentation demonstrating diffuse conjunctival injection, a paracentral area with corneal haze and an overlying epithelial defect, and an inferior 5 mm hemorrhagic hypopyon. (b) Ultrasound demonstrating vitreous hyperechogenicities, representing spill-over inflammation from the anterior segment pathology. (c) Fluorescein stain at 1 week demonstrating a large epithelial defect which persisted throughout the patient’s inpatient course

Figure 2

(a) Hematoxylin and eosin staining of the corneal button taken at time of corneal transplantation on day 54 of admission demonstrating necrotic stroma with an inflammatory infiltrate. (b) Grocott methenamine silver stain demonstrating degenerating fungal hyphal elements within the corneal button indicated by the red arrows