Wilhelmus K R, Jones D B
Sid W. Richardson Ocular Microbiology Laboratory, Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA.
Trans Am Ophthalmol Soc. 2001;99:111-30; discussion 130-2.
To determine the risk factors and clinical signs of Curvularia keratitis and to evaluate the management and outcome of this corneal phaeohyphomycosis.
We reviewed clinical and laboratory records from 1970 to 1999 to identify patients treated at our institution for culture-proven Curvularia keratitis. Descriptive statistics and regression models were used to identify variables associated with the length of antifungal therapy and with visual outcome. In vitro susceptibilities were compared to the clinical results obtained with topical natamycin.
During the 30-year period, our laboratory isolated and identified Curvularia from 43 patients with keratitis, of whom 32 individuals were treated and followed up at our institute and whose data were analyzed. Trauma, usually with plants or dirt, was the risk factor in one half; and 69% occurred during the hot, humid summer months along the US Gulf Coast. Presenting signs varied from superficial, feathery infiltrates of the central cornea to suppurative ulceration of the peripheral cornea. A hypopyon was unusual, occurring in only 4 (12%) of the eyes but indicated a significantly (P = .01) increased risk of subsequent complications. The sensitivity of stained smears of corneal scrapings was 78%. Curvularia could be detected by a panfungal polymerase chain reaction. Fungi were detected on blood or chocolate agar at or before the time that growth occurred on Sabouraud agar or in brain-heart infusion in 83% of cases, although colonies appeared only on the fungal media from the remaining 4 sets of specimens. Curvularia was the third most prevalent filamentous fungus among our corneal isolates and the most common dematiaceous mold. Corneal isolates included C senegalensis, C lunata, C pallescens, and C prasadii. All tested isolates were inhibited by 4 micrograms/mL or less of natamycin. Topical natamycin was used for a median duration of 1 month, but a delay in diagnosis beyond 1 week doubled the average length of topical antifungal treatment (P = .005). Visual acuity improved to 20/40 or better in 25 (78%) of the eyes.
Curvularia keratitis typically presented as superficial feathery infiltration, rarely with visible pigmentation, that gradually became focally suppurative. Smears of corneal scrapings often disclosed hyphae, and culture media showed dematiaceous fungal growth within 1 week. Natamycin had excellent in vitro activity and led to clinical resolution with good vision in most patients with corneal curvulariosis. Complications requiring surgery were not common but included exophytic inflammatory fungal sequestration, treated by superficial lamellar keratectomy, and corneal perforation, managed by penetrating keratoplasty.
确定弯孢霉性角膜炎的危险因素和临床体征，并评估这种角膜暗色丝孢霉病的治疗方法及预后。
我们回顾了1970年至1999年的临床和实验室记录，以确定在我们机构接受治疗且经培养证实为弯孢霉性角膜炎的患者。使用描述性统计和回归模型来确定与抗真菌治疗时长及视力预后相关的变量。将体外药敏结果与局部应用那他霉素所获得的临床结果进行比较。
在这30年期间，我们实验室从43例角膜炎患者中分离并鉴定出弯孢霉，其中32例在我们研究所接受治疗并进行随访，其数据被用于分析。外伤，通常是被植物或泥土划伤，是半数患者的危险因素；69%的病例发生在美国墨西哥湾沿岸炎热潮湿的夏季。临床表现多样，从中央角膜的浅表、羽毛状浸润到周边角膜的化脓性溃疡。前房积脓不常见，仅在4只眼（12%）中出现，但提示后续并发症的风险显著增加（P = 0.01）。角膜刮片染色涂片的敏感度为78%。可通过泛真菌聚合酶链反应检测到弯孢霉。在萨布罗琼脂培养基或脑心浸液培养基上生长之前或同时，83%的病例在血琼脂或巧克力琼脂培养基上检测到真菌，尽管其余4份标本的菌落仅出现在真菌培养基上。弯孢霉是我们角膜分离菌株中第三常见的丝状真菌，也是最常见的暗色霉菌。角膜分离菌株包括塞内加尔弯孢霉、新月弯孢霉、苍白弯孢霉和普拉萨德弯孢霉。所有受试菌株均被4微克/毫升或更低浓度的那他霉素抑制。局部应用那他霉素的中位疗程为1个月，但诊断延迟超过1周会使局部抗真菌治疗的平均时长增加一倍（P = 0.005）。25只眼（78%）的视力提高到20/40或更好。
弯孢霉性角膜炎通常表现为浅表羽毛状浸润，很少有可见色素沉着，逐渐发展为局部化脓。角膜刮片涂片常可发现菌丝，培养基在1周内显示暗色真菌生长。那他霉素具有良好的体外活性，能使大多数角膜弯孢霉病患者临床症状消退且视力良好。需要手术治疗的并发症并不常见，但包括外生性炎性真菌包块，通过浅表板层角膜切除术治疗，以及角膜穿孔，通过穿透性角膜移植术处理。
