ISHAM Symposium: S33: Ocular aspects of Fungal Infections Friday, 8 May 2015, ; MR101/102 Level 1
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1 ISHAM Symposium: S33: Ocular aspects of Fungal Infections Friday, 8 May 2015, ; MR101/102 Level 1 Chairs: Ariya Chindamporn, TH and Phillip A Thomas, IN 14:15-14:35 AGENDA Clinical overview of ocular fungal infections #935 Peter McCluskey, AUS 14:35-14:50 Neglected fungal infections of eye #722 Ariya Chindamporn, TH 14:50-15:10 15:10-15:25 Fungal virulence factors in ocular infections #936 The challenges in Mycotic keratitis in horses and dogs #938 Philip A Thomas, IN Andrew Turner, AUS 15:25-15:45 Host factors in mycotic keratitis Lalitha Prajna, IN
2 19 th Melbourne Ocular aspects of Fungal Infections Neglected fungal infections of eye Ariya Chindamporn Department of Microbiology Faculty of Medicine, Chulalongkorn University May 8, 2015
3 Outline Laboratory investigation Risk factors Epidemiology Cases
4 Flow chart : laboratory investigation Cornea scrapings, biopsy Direct from specimens Fungal Isolation KOH preparation: 75-90% Macroscopic Exam. Calcofluor: 80-90% Microscopic Exam. GMS: 89-98% Zoospore production PCR & Sequencing PCR & Sequencing %sensitivity (Thomas PA., 2003 Eye:17 (852-62)
5 Corneal scraping, staining, inoculation
6 Specimen collection for PCR Cornea, Vitreous, Aqueous For PCR FFPE
7 Risk factors HISTORY is important. o Trauma : Dust, Leaf, Stone, Water, Contact len o Swimming o Occupation : working outdoor/indoor o Host factors: diabetes mellitus o Fungal virulence factors o > 5-10 days
8 Frequence isolates of Fungal MOLD Hyaline hyphae : Fusarium spp.: F. solani, F. oxysporum Aspergillus spp. : A. fumigatus, A. flavus Scedosporium spp. : S. apiospermum Penicillium spp. : P. spinulosum, P. citrinum Acremoniium spp. ( A. potronii, A. kiliense) Dematiaceous fungi Curvularia spp. (C. lunata, C. geniculate, C. senegalensis ) Bipolaris spp. ( B. spicifera, B. hawaiiensis) Exserohilum spp. (E. rostratum, E. longirostrata) Coelomycetes (Lasiodiplodia, Colletotrichum) Alternaria Yeast Candida spp. (C. albicans) Rhodotorula Others Pythium insidiosum Lagenidium albertoi Modified from Thomas PA., 2003 Eye :17:852-62
9 Epidemiology 1352 proven cases, a tertiary care hosp. South India -10 yr. ( ) (Gopinathan et al., 2002 Cornea:21:555-9) > 99% caused by mold; Male > Female: 2.5:1; Age: Risk: systemic factors : DM 654 eyes in Shandong Eye Institute, North China, Jan Dec 2004 (Zhong XL., et al 2006 Opthalmol 113(11):1943-8) 62% of total cases : fungal keratitis Fusarium spp. : F. solani 73%, 437 eyes) Aspergillus spp. : A. flavus 12%, 72 eyes Prevalence : the season, more : Oct to Dec than Jul to Sep. KOH preparation 88% positive, Culture 91% Histopath. staining: most effective, resulting 98% but need to reveal genus and species. 997 cases in eastern India, Jul 2006 and Dec % as fungal keratitis. The geographical place and climate affected the prevalence (2012) : 36.7% in Southern, 36.3%, 25.6%, 7.3% in Western, North-eastern, and Northern India, in order. Katara SR., et al., (6); Acta Medica Iranica
10 Mimiking fungal infection
11 Conventional approach KOH-preparation: rare septate hyphae Histopathology: GMS Pythium insidiosum Kingdom Straminipila/ Stramenopila
12 Natural resource Pythiosis in Thailand : Clinical case HIGHEST INCIDENCE in Human Supanpandu et al., Med Mycol 2008 C : Central NE: Northeastern S : Southern N : Northern E : Eastern 12 Krajejun et al., CID 2006
13 Specimens KOH Culture PCR Cornea Scraping/ biopsy 1 st d 2 nd d 2wk 1 st d 2 nd d 2 wk 1 st d 2 nd d 2 wk Aqueous Vitreous Vitreous and Iris Lens Lens IFN ITS Cornea Rt.Lens KOH: Positive
14 Rt.Cornea KOH: Positive Culture: Positive PCR: Positive
15 IMPORTED CASE
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21 Lagenidium sp. Ocular Infection Mimicking Ocular Pythiosis U Riengprayoon et al., JCM 2013:51(8): yr. housewife admitted in a tertiary care hospital: lid swelling, pain, redness, & itching for 3 weeks, visit physician,.. visual acuity: finger counting at 1 foot slit lamp ex.: ciliary injection & a yellowish, midstromal, reticular pattern corneal infiltration measuring 5x5.6 mm. with feathery edge corneal epitherial defect 4x3 mm in dia. over the infiltrated area posterior eye segment by ultrasound: no sign of endophthalmitis unsuccessfully treated with systemic and topical drugs
22 Lagenidium sp.: Mimicking Ocular Infection Fungal elements in corneal stroma by confocal microscopy Broad, rare septate hyphae by KOH preparation Broad hyphae by GMS U Riengprayoon et al., JCM 2013:51(8):2778
23 Treatment - First : systemic & topical antibiotics: worse - Presumed to be fungal infection: - topical : cefazolin, amikacin, natamycin, voriconazole, Referred to tertiary hospital - Result from ocular confocal micro. & frequency of pythiosis - oral terbinafine, itraconazole & topical natamycin with Pythium Insidiosum Antigen (PIA) vaccine - worse - Twice of Penetrating keratoplasty (PK) - 10 mo. later : no recurrent of infection
24 Susceptibility result *The value of Minimal Inhibitory Concentration (MIC) Agents Lagenidium spp. Clinical P. insidiosum Enviromental P. insidiosum Amphotericin B Terbinafine Voriconazole Itraconazole Fluconazole Anidulafungin Caspofungin TB/VO Indifference Indifference Indifference TV/IT Indifference Indifference Indifference
25 Parsimony Analysis ITS 1000 Bootstrap Parsimony analysis, ITS 1000 Bootstrap Lagenidium albertoi Vol. 21, No. 2, February 2015
26 Sharma et al., 2014 Calcofluor white staining 35C, 3 d. PDA LCB wet mount Sporangia with zoospore
27 Take home message Rapid and accurate diagnosis, leading the right treatment is required: Communication with physicians Direct exam. & Culture still gold standard Molecular identification Very rapid growth, no sporulation No response to antifungal agents: Think about parafungal infection
28
Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok,
JCM Accepts, published online ahead of print on 5 June 2013 J. Clin. Microbiol. doi:10.1128/jcm.00783-13 Copyright 2013, American Society for Microbiology. All Rights Reserved. 1 Lagenidium sp. ocular
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