Fusarium keratitis in South Florida: a clinico-microbiological correlation
Paula A. Sepulveda-Beltran1,2, Piero Carletti1, Heather Durkee2, Katherine D. Leviste2, Victor Banda1, Jean-Marie Parel2,
Guillermo Amescua1,2, Darlene Miller3
1Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida; 2Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida; 3Ocular Microbiology Laboratory, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
Purpose: To evaluate species diversity of Fusarium isolates recovered from patients with Fungal keratitis in South Florida and compare them with their clinical characteristics, management, and outcomes.
Methods: A combination of PCR and DNA sequencing was used to confirm and classify 101 fusarium isolates recovered from patients presenting to the BPEI with fungal keratitis between January 2016 and May 2022. A retrospective review collecting baseline demographic information, risk factors for infectious keratitis, clinical characteristics, and therapeutic outcomes was performed. 25 patients were excluded from statistical analyses due to missing critical information, leaving a cohort of 76 patients. Independent t-tests were used to compare the means of continuous variables, and Chi-square to compare categorical variables. The main outcomes included treatment failure and clinical resolution. Treatment failure was defined as progression to corneal perforation, therapeutic penetrating keratoplasty (TPK), or endophthalmitis. Clinical resolution was defined as not meeting the criteria for treatment failure.
Results: Isolates (n=101) : 89 of 101 isolates (88.1%) belonged to the Fusarium solani species complex (FSSC), of which the solani species (n=71, 70.2%) was the most commonly identified, followed by falciforme (n=13, 12.8%), and petroliphilum (n=3, 2.9%). No statistical difference in the clinical characteristics, management, and outcomes was found between species groups (FSSC vs non-FSSC).
Clinical features (n=101) : The mean age of the study population was 53±16 years; 68 (67.3%) were male. Mean follow-up time was 8.45±11.9 months. Risk factors included trauma with organic matter (n=39, 38.6%) and contact lens and topical steroid use within 30 days of symptom onset (n=38, 37.6%; n=11, 10.9%). The mean time from symptom onset to initial presentation was 0.31 ± 0.32 months. At presentation, 94 eyes (92.1%) had stromal infiltrates (mean area: 14.2±14.5 mm2), 38 (37.6%) a hypopyon, and 3 (3%) scleral involvement. Stromal infiltrates were larger in those with treatment failure compared to those with clinical resolution (21.89±21.9 mm2 vs 10.41±8.66 mm2, p=0.022). At presentation, 23 patients (22.7%) had begun treatment with topical steroids, and 98 (97%) with topical antibiotics (n=95, 96.9% with an aminoglycoside; n=84, 85.7% with a fluoroquinolone). Antifungal monotherapy was used in 52 patients (n=51, 50.4% received natamycin; n=1, 0.99% voriconazole), whereas two antifungals were required in 25 patients (24.7%), three in 16 (15.8%), and four in 3 (3%). Intrastromal or intraocular antifungals were required in 20 (19.8%) patients.
Clinical outcomes (n=76) : Clinical resolution was achieved in 50 eyes (65.7%) 2.70±2.50 months after presentation. Treatment failure occurred in 26 eyes (34.2%) 0.95±1.06 months after presentation; of these, 23 (88.4%) required TPK, and 3 (11.5%) developed endophthalmitis. Eyes with treatment failure, compared to those with clinical resolution, had a significantly longer time from symptom onset to presentation (0.43 ± 0.33 vs 0.22 ± 0.24, p<0.001), as well as from symptom onset to initiation of antifungals (0.72 ± 0.63 vs 0.34 ± 0.24, p<0.001).
Conclusions: Members of the FSSC remain the most frequently recovered Fusarium species from fungal keratitis in South Florida. Delayed time to presentation and initiation of antifungals were associated with adverse clinical outcomes. However, a difference in outcomes was not observed between FSSC and non-FSSC isolates.
Support: Edward D. and Janet K. Robson Foundation (Tulsa, OK); the Florida Lions Eye Bank and the Beauty of Sight Foundation (Miami, FL); NIH Center Core Grant P30EY14801; the Henri and Flore Lesieur Foundation (Chicago, IL)(Parel).