Clinicopathological correlation in fungal keratitis and a possible evidence of opportunistic infection: a report of two cases

The authors describe two cases of fungal keratitis which, upon histopathological examination, are found to have in common the absence of epithelium, without ulceration and the lack of integrity of the Bowman's layer with the presence of fungal forms in their interior. Through them the authors suggest probable mechanisms of recurrence of fungal keratitis, highlighting the possible existence of an "unusual external route" that would occur by the fungus penetration through the full Bowman layer. Although these findings appear not yet reported or recovered in the ophthalmic literature, the authors suggest that they could be possible opportunistic infection signals which, however, require more evidence to be considered as such.

Keywords:
keratitis; Eye infections, fungal; Cornea/histopathology, Cornea/microbiology; Opportunistic infections; Case reports

Authorship

Karine Feitosa Ximenes

Department of Ocular Pathology of the Eye Bank, Hospital Geral de Fortaleza, Fortaleza (CE), Brazil.Hospital Geral de FortalezaBrazilFortaleza, CE, BrazilDepartment of Ocular Pathology of the Eye Bank, Hospital Geral de Fortaleza, Fortaleza (CE), Brazil.

Karla Feitosa Ximenes Vasconcelos

Hospital Geral de Fortaleza, Fortaleza (CE), Brazil; Fundação de Ciência e Pesquisa Maria Ione Xerez Vasconcelos; Fortaleza (CE), Brazil.Hospital Geral de FortalezaBrazilFortaleza, CE, BrazilHospital Geral de Fortaleza, Fortaleza (CE), Brazil; Fundação de Ciência e Pesquisa Maria Ione Xerez Vasconcelos; Fortaleza (CE), Brazil.

Fernando Queiroz Monte

Corresponding author: Karine Feitosa Ximenes, R. Andrade Furtado, 150 - Apto: 1501- Cocó - Fortaleza - Ceará ZIP Code: 60192-070, Phone No.: (85) 3262-6781, (85) 9673-3132. E-mail: karinefx@gmail.com

The authors declare no conflicts of interests.

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Figures

Figures (5)

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Figure 1
Clinical development of fungal keratitis and its recurrence after therapeutic penetrating keratoplasty in case 1. a) Clinical aspect of fungal keratitis that developed with progressive worsening despite clinical treatment. b) Appearance in the immediate postoperative period of therapeutic penetrating keratoplasty showing that all visibly infected tissue had been removed. c) Recurrence of infection in the postoperative period, after progressive deterioration of the clinical profile. d.) Transparent graft with no signs of recurrence of the infection in about two months of follow-up after the second therapeutic penetrating keratoplasty.

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Figure 2
Histopathological examination findings in the tissue from the first keratoplasty of case 1. a) Presence of fungi only in the form of yeast. Yeasts (black arrows). Spores (red arrows). (paraffin, H.E. – 400x). b) Yeasts within the Descemet’s membrane (black arrows). Translucent yeast (green arrow) and spores (red arrows) in the anterior chamber. (paraffin, H.E. – 400x).

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Figure 3
Histopathological examination findings in the tissue from the second keratoplasty of case 1. a) Presence of fungi only in the form of hyphae and yeast. Yeasts (black arrows). Spores (red arrows). hyphae (blue arrows). Pseudo-hyphae (orange arrow). (paraffin, H.E. –500x). b) Intact Bowman’s layer with yeasts (black arrows) and spores (red arrows) inside. (paraffin, H.E. – 500x). c) Intact Descemet’s membrane with yeasts inside (black arrows). Spores inside the Descemet are not marked. In the deep stroma there is a pseudo-hyphae (orange arrow). In the anterior chamber yeasts are seen (black arrows). (paraffin, H.E. – 500x).d

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Figure 4
Histopathological examination findings in the tissue from the first keratoplasty of case 2. a) Bowman’s layer intact to its full extent. Presence of spores and yeast predominatly in the anterior corneal stroma. Absence of inflammatory reaction and fungi in the anterior chamber. (paraffin, H.E. – 125x). b) Bowman’s layer intact to its full extent. Presence of spores and yeast predominatly in the anterior corneal stroma. (paraffin, H.E. – 400x). c) Bowman’s layer intact to its full extent. Presence of spores and yeast predominatly in the anterior corneal stroma. (paraffin, H.E. – 500x).

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Figure 5
Histopathological examination findings in the tissue from the second keratoplasty of case 2. a) Presence of spores and yeast predominatly in the anterior corneal stroma. (paraffin, H.E. – 600x). b) Bowman’s layer intact to its full extent with spores inside. Spores inside the Bowman’s layer (red arrow). (paraffin, H.E. – 500x).

Figure 1 Clinical development of fungal keratitis and its recurrence after therapeutic penetrating keratoplasty in case 1. a) Clinical aspect of fungal keratitis that developed with progressive worsening despite clinical treatment. b) Appearance in the immediate postoperative period of therapeutic penetrating keratoplasty showing that all visibly infected tissue had been removed. c) Recurrence of infection in the postoperative period, after progressive deterioration of the clinical profile. d.) Transparent graft with no signs of recurrence of the infection in about two months of follow-up after the second therapeutic penetrating keratoplasty.

Figure 2 Histopathological examination findings in the tissue from the first keratoplasty of case 1. a) Presence of fungi only in the form of yeast. Yeasts (black arrows). Spores (red arrows). (paraffin, H.E. – 400x). b) Yeasts within the Descemet’s membrane (black arrows). Translucent yeast (green arrow) and spores (red arrows) in the anterior chamber. (paraffin, H.E. – 400x).

Figure 3 Histopathological examination findings in the tissue from the second keratoplasty of case 1. a) Presence of fungi only in the form of hyphae and yeast. Yeasts (black arrows). Spores (red arrows). hyphae (blue arrows). Pseudo-hyphae (orange arrow). (paraffin, H.E. –500x). b) Intact Bowman’s layer with yeasts (black arrows) and spores (red arrows) inside. (paraffin, H.E. – 500x). c) Intact Descemet’s membrane with yeasts inside (black arrows). Spores inside the Descemet are not marked. In the deep stroma there is a pseudo-hyphae (orange arrow). In the anterior chamber yeasts are seen (black arrows). (paraffin, H.E. – 500x).d

Figure 4 Histopathological examination findings in the tissue from the first keratoplasty of case 2. a) Bowman’s layer intact to its full extent. Presence of spores and yeast predominatly in the anterior corneal stroma. Absence of inflammatory reaction and fungi in the anterior chamber. (paraffin, H.E. – 125x). b) Bowman’s layer intact to its full extent. Presence of spores and yeast predominatly in the anterior corneal stroma. (paraffin, H.E. – 400x). c) Bowman’s layer intact to its full extent. Presence of spores and yeast predominatly in the anterior corneal stroma. (paraffin, H.E. – 500x).

Figure 5 Histopathological examination findings in the tissue from the second keratoplasty of case 2. a) Presence of spores and yeast predominatly in the anterior corneal stroma. (paraffin, H.E. – 600x). b) Bowman’s layer intact to its full extent with spores inside. Spores inside the Bowman’s layer (red arrow). (paraffin, H.E. – 500x).

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Clinicopathological correlation in fungal keratitis and a possible evidence of opportunistic infection: a report of two cases

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[1] Corresponding author: Karine Feitosa Ximenes, R. Andrade Furtado, 150 - Apto: 1501- Cocó - Fortaleza - Ceará ZIP Code: 60192-070, Phone No.: (85) 3262-6781, (85) 9673-3132. E-mail: karinefx@gmail.com