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      Fungal keratitis in patients with corneal ulcer attending Minilik II Memorial Hospital, Addis Ababa, Ethiopia

      research-article
      Author(s): 1 , 2 ,
      Publication date (Electronic):
      Journal: BMC Ophthalmology
      Publisher: BioMed Central
      Keywords: Fungal keratitis, Risk factors, Filamentous fungi, Yeasts

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          Abstract

          Background

          Fungal keratitis is an important cause of corneal blindness all over the world. Although there are several reports on fungal keratitis from developing and developed countries, fungal keratitis in Ethiopia is poorly known. The aim of this study was to determine the prevalence of fungal keratitis and spectrum of fungi implicated in causing the infection.

          Methods

          The present study was a single institutional cross-sectional study carried out in Minilik II Memorial Hospital eye clinic, Addis Ababa, Ethiopia from September 2014 to August 2015. Corneal scraping was obtained under aseptic condition with sterile 21 gauge needle by an ophthalmologist from patients suspected of microbial keratitis. Each scraping was inoculated onto Sabouraud Dextrose Agar in C-shaped streaks and incubated at 25 °C aerobically for four weeks. Cultures of mycelia fungi were identified by examining macroscopic and microscopic characteristics of their colonies. Yeasts were identified by employing biochemical and assimilation test procedures and using CHROMagar Candida culture. All data were coded, double entered and analyzed using SPSS version 20.

          Result

          Out of 153 cases of microbial keratitis, fungi were recovered from 69 patients giving fungal keratitis prevalence of 45.1. Patients from rural areas were significantly affected than patients in urban regions ( P = 0.005). Age groups of 25–34 ( P = 0.017) and 15–24 years ( P = 0.008) were significantly affected. Fungal keratitis was significantly associated with farmers ( P = 0.0001), daily laborers ( P = 0.0001), unemployed ( P = 0001) and students ( P = 0.004). Fungal keratitis was statistically associated with trauma ( P = 0.006), and diabetes ( P = 0.024). Seventy six fungal isolates were recovered, of which molds accounted 63 (82.9 %) of the total isolates. Fusarium and Aspergillus species were the two predominant molds accounting 27.6 and 25 % of the total isolates respectively. Yeast isolates accounted only 17.1 %.

          Conclusion

          High prevalence of fungal keratitis recorded in the present study, highlights the need for nationwide study on fungal keratitis and precise identification of the causative fungi and institution of appropriate treatment strategy.

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          Most cited references31

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          Mycotic keratitis: epidemiology, diagnosis and management.

          J Kaliamurthy, Arne Thomas (2013)
          Mycotic keratitis (an infection of the cornea) is an important ocular infection, especially in young male outdoor workers. There are two frequent presentations: keratitis due to filamentous fungi (Fusarium, Aspergillus, phaeohyphomycetes and Scedosporium apiospermum are frequent causes) and keratitis due to yeast-like fungi (Candida albicans and other Candida species). In the former, trauma is usually the sole predisposing factor, although previous use of corticosteroids and contact lens wear are gaining importance as risk factors; in the latter, there is usually some systemic or local (ocular) defect. The clinical presentation and clinical features may suggest a diagnosis of mycotic keratitis; increasingly, in vivo (non-invasive) imaging techniques (confocal microscopy and anterior segment optical coherence tomography) are also being used for diagnosis. However, microbiological investigations, particularly direct microscopic examination and culture of corneal scrape or biopsy material, still form the cornerstone of diagnosis. In recent years, the PCR has gained prominence as a diagnostic aid for mycotic keratitis, being used to complement microbiological methods; more importantly, this molecular method permits rapid specific identification of the aetiological agent. Although various antifungal compounds have been used for therapy, management of this condition (particularly if deep lesions occur) continues to be problematic; topical natamycin and, increasingly, voriconazole (given by various routes) are key therapeutic agents. Therapeutic surgery, such as therapeutic penetrating keratoplasty, is needed when medical therapy fails. Increased awareness of the importance of this condition is likely to spur future research initiatives. © 2013 The Authors Clinical Microbiology and Infection © 2013 European Society of Clinical Microbiology and Infectious Diseases.
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            Review of epidemiological features, microbiological diagnosis and treatment outcome of microbial keratitis: Experience of over a decade

            Usha Gopinathan, Savitri Sharma, Prashant Garg … (2009)
            Purpose: To review the epidemiological characteristics, microbiological profile, and treatment outcome of patients with suspected microbial keratitis. Materials and Methods: Retrospective analysis of a non-comparative series from the database was done. All the patients presenting with corneal stromal infiltrate underwent standard microbiologic evaluation of their corneal scrapings, and smear and culture-guided antimicrobial therapy. Results: Out of 5897 suspected cases of microbial keratitis 3563 (60.4%) were culture-proven (bacterial – 1849, 51.9%; fungal – 1360, 38.2%; Acanthamoeba – 86, 2.4%; mixed – 268, 7.5%). Patients with agriculture-based activities were at 1.33 times (CI 1.16–1.51) greater risk of developing microbial keratitis and patients with ocular trauma were 5.33 times (CI 6.41–6.44) more likely to develop microbial keratitis. Potassium hydroxide with calcofluor white was most sensitive for detecting fungi (90.6%) and Acanthamoeba (84.0%) in corneal scrapings, however, Gram stain had a low sensitivity of 56.6% in detection of bacteria. Majority of the bacterial infections were caused by Staphylococcus epidermidis (42.3%) and Fusarium species (36.6%) was the leading cause of fungal infections. A significantly larger number of patients (691/1360, 50.8%) with fungal keratitis required surgical intervention compared to bacterial (799/1849, 43.2%) and Acanthamoeba (15/86, 17.4%) keratitis. Corneal healed scar was achieved in 75.5%, 64.8%, and 90.0% of patients with bacterial, fungal, and Acanthamoeba keratitis respectively. Conclusions: While diagnostic and treatment modalities are well in place the final outcome is suboptimal in fungal keratitis. With more effective treatment available for bacterial and Acanthamoeba keratitis, the treatment of fungal keratitis is truly a challenge.
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              Microbial keratitis in South India: influence of risk factors, climate, and geographical variation.

              M Bharathi, Smriti R. Ramakrishnan, R Meenakshi … (2015)
              To determine the influence of risk factors, climate, and geographical variation on the microbial keratitis in South India. A retrospective analysis of all clinically diagnosed infective keratitis presenting between September 1999 and August 2002 was performed. A standardised form was filled out for each patient, documenting sociodemographic features and information pertaining to risk factors. Corneal scrapes were collected and subjected to culture and microscopy. A total of 3,183 consecutive patients with infective keratitis were evaluated, of which 1,043 (32.77%) were found to be of bacterial aetiology, 1,095 (34.4%) were fungal, 33 (1.04%) were Acanthamoeba, 76 (2.39%) were both fungal and bacterial, and the remaining 936 (29.41%) were found to be culture negative. The predominant bacterial and fungal pathogens isolated were Streptococcus pneumoniae (35.95%) and Fusarium spp. (41.92%), respectively. Most of the patients (66.84%) with fungal keratitis were between 21 and 50 years old, and 60.21% of the patients with bacterial keratitis were older than 50 (p < 0.0001) (95% CI: 5.19-7.19). A majority of patients (64.75%) with fungal keratitis were agricultural workers (p < 0.0001) [odds ratio (OR): 1.4; 95% CI: 1.19-1.61], whereas bacterial keratitis occurred more commonly (57.62%) in nonagricultural workers (p < 0.0001) (OR: 2.88; 95% CI: 2.47-3.36). Corneal injury was identified in 2,256 (70.88%) patients, and it accounted for 92.15% in fungal keratitis (p < 0.0001) (OR: 7.7; 95% CI: 6.12-9.85) and 100% in Acanthamoeba keratitis. Injuries due to vegetative matter (61.28%) were identified as a significant cause for fungal keratitis (p < 0.0001) (OR: 23.6; 95% CI: 19.07-29.3) and due to mud (84.85%) for Acanthamoeba keratitis (p < 0.0001) (OR: 26.01; 95% CI: 3.3-6.7). Coexisting ocular diseases predisposing to bacterial keratitis accounted for 68.17% (p < 0.0001) (OR: 33.99; 95% CI: 27.37-42.21). The incidence of fungal keratitis was higher between June and September, and bacterial keratitis was less during this period. The risk of agricultural predominance and vegetative corneal injury in fungal keratitis and associated ocular diseases in bacterial keratitis increase susceptibility to corneal infection. A hot, windy climate makes fungal keratitis more frequent in tropical zones, whereas bacterial keratitis is independent of seasonal variation and frequent in temperate zones. Microbial pathogens show geographical variation in their prevalence. Thus, the spectrum of microbial keratitis varies with geographical location influenced by the local climate and occupational risk factors.
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                Author and article information

                Contributors
                Tihtina Kibret: askulove2005@gmail.com
                Adane Bitew: bitewadane@gmail.com
                Journal
                Journal ID (nlm-ta): BMC Ophthalmol
                Journal ID (iso-abbrev): BMC Ophthalmol
                Title: BMC Ophthalmology
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2415
                Publication date (Electronic): 30 August 2016
                Publication date PMC-release: 30 August 2016
                Publication date Collection: 2016
                Volume: 16
                Issue: 1
                Electronic Location Identifier: 148
                Affiliations
                [1 ]Department of Medical Laboratory Sciences, Tirunesh Beijing Hospital, Addis Ababa, Ethiopia
                [2 ]Department of Medical Laboratory Sciences, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
                Article
                Publisher ID: 330
                DOI: 10.1186/s12886-016-0330-1
                PMC ID: 5004268
                SO-VID: ce4ded85-9d84-4dec-880e-ed3685c38a84
                Copyright © © The Author(s). 2016
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 26 October 2015
                Date accepted : 23 August 2016
                Funding
                Funded by: no funding agent
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2016

                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: fungal keratitis,risk factors,filamentous fungi,yeasts
                Data availability:
                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: fungal keratitis, risk factors, filamentous fungi, yeasts

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