A 56-year-old male farmer presented with a 1-week history of painful visual loss after trauma with a rice husk to his right eye. He had no history of diabetes or immune dysfunction. He was hospitalized a month previously for COVID-19 and had received five injections of intravenous methyl prednisolone (500 mg). At presentation, his visual acuity was perception of light. The cornea showed a full-thickness infection (Figure 1A). Ultrasonography showed a clear vitreous cavity (Figure 1B). Microbiology from corneal scrapings revealed fungal filaments (Figure 1C). Natamycin 5% eye drops hourly and oral ketoconazole 200 mg twice daily were started. However, the infection progressed rapidly (Figure 1D and E), and an urgent corneal transplant was done. Because the lens was also infected, cataract extraction was also performed (surgery 1). Despite this, the condition worsened over 2 weeks. The infection spread deeper to the posterior segment of the eye (endophthalmitis) (Figure 1F and G), necessitating vitrectomy and injections of amphotericin B (5 µg) and voriconazole (100 μg) (surgery 2). Corneal tissue grew Fusarium solani (Figure 1H). Histopathology showed deep invasion (Figure 1I–L). Over the next 2 weeks, there appeared to be improvement; hence, topical prednisolone acetate 1% was started (4 weeks after transplant or 2 weeks after vitrectomy) (Figure 2A–D). At 5 weeks post-transplant, the patient seemed better; but, suddenly at 6 weeks, he presented with recurrence of infection in the graft (Figure 2E–H). As a last effort, repeat transplantation with intraocular wash was performed (surgery 3). One month later (Figure 2 I and J), the infection had resolved but the eye was already shrinking (phthisis). Histopathology again revealed fungal filaments (Figure 2K–N).
Fungal keratitis can worsen rapidly when associated with predisposing factors such as trauma, topical corticosteroids use, or uncontrolled diabetes mellitus.1,2 Therapy for COVID-19 infection often includes systemic glucocorticoids, among other agents, for acute respiratory involvement.3 Our patient developed infection 1 month after having COVID-19. His condition worsened despite aggressive medical and surgical management. Decreased production of CD4+ T cells and CD8+ T cells, and decreased cytokines in COVID-19 have been associated with systemic immunosuppression, predisposing to secondary opportunistic infections (especially fungal).4,5 Fusarium infection itself is a poor prognostic factor because it is known to progress to endophthalmitis, which invariably has a poor outcome.2 We postulate that the weakened host immunity and the use of glucocorticoids in COVID-19 may have been an additional risk factor for the poor outcome in our patient.
We thank Savitri Sharma, Network Head, Jhaveri Microbiology Centre, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India.
Dan J , Zhou Q , Zhai H , Cheng J , Wan L , Ge C , Xie L , 2018. Clinical analysis of fungal keratitis in patients with and without diabetes. PLoS One 13: e0196741.
Wan L , Cheng J , Zhang J , Chen N , Gao Y , Xie LX , 2019. Risk factors, treatment strategies, and outcomes of endophthalmitis associated with severe fungal keratitis. Retina 39: 1076–1082.
Song G , Liang G , Liu W , 2020. Fungal co-infections associated with global COVID-19 pandemic: a clinical and diagnostic perspective from China. Mycopathologia 7: 1–8.
Lei Y et al.2020. Fungal antigenemia in patients with severe coronavirus disease 2019 (COVID-19): the facts and challenges. J Microbiol Immunol Infect 53: 657–665.
Sanders JM , Monogue ML , Jodlowski TZ , Cutrell JB , 2020. Pharmacologic treatments for coronavirus disease 2019 (COVID‐19): a review. JAMA 323: 1824–1836.