Fungal Keratitis Associated with Viral Keratitis

Microbial keratitis caused by more than one microorganism is rare. It may occur as a coinfection or as a secondary infection superimposed with an existent microorganism. [1] Both infectious and immune mechanisms are implicated in microbial keratitis. Herein, we report an unusual clinical case of viral and fungal mixed infection. Written informed consent was obtained from the patient. A 31‑year‑old man complained of red left eye for 10 days; accompanied with eye pain, photophobia, and blurred vision for 7 days and exacerbated in the next 2 days. At the beginning, he visited a hospital in Beijing. Corneal smear and the scrapings culture results were negative. Then he was treated as a patient with viral keratitis. He used topical ganciclovir eye gel, interferon, levofloxacin, pranoprofen eye drops, deproteinized calf blood extract eye gel, and oral famciclovir tablets. Ocular manifestation was alleviated obviously according to the patient's description and medical record. At 3 days before, he visited our hospital, the patient suffered from heavy cold and recovered after he took over‑the‑counter cold medications. Unfortunately, he felt severe eye pain and photophobia for 2 days before he was referred to our hospital. He had neither trauma history nor wore contact lenses previously. The visual acuity of his right eye was 20/20. No significant abnormality was detected in the right eye. While the visual acuity of the left eye was counting finger in front of the eye and could not be corrected. The clinical manifestation was showed in the Figure 1a. After the patient was admitted, a repeat corneal smear was performed, and the scrapings were sent for bacterial (aerobes/anaerobes), fungal, and Acanthamoeba cultures and tested for antibiotic sensitivity. Fungal hyphae and epithelium were found in corneal smear [Figure 1g and 1h]. However, cultures were negative. The patient was diagnosed with fungal keratitis and viral keratitis based on previous medical history, clinical manifestations, and corneal smear results. The procedure of treatment was divided into four stages. 1. Rapid remission stage lasted approximately 1 week [Figure 1b]. Combined antifungal, antiviral, and anti‑inflammatory therapy was administered, including 5% natamycin eye drops (q1h), ganciclovir eye gel (tid), pranoprofen eye drops (qid), tropicamide (a cycloplegic compound) eye drops (tid), and oral acyclovir tablets (400 mg, qid). Hypopyon disappeared 1 day after treatment, but fungi were persistent in corneal scrapings 4 days after treatment. 2. Chronic lag stage lasted more than 2 weeks. The patient complained about eye pain …