An analysis of the clinical behavior An analysis of the clinical behavior of mycotic keratitis caused by non of mycotic keratitis caused by non
sporing moldssporing molds
The authors have no financial interest The authors have no financial interest in the subject matter of this posterin the subject matter of this poster
Dr. Revathi RajaramanDr. Revathi RajaramanAravind Eye HospitalAravind Eye Hospital
CoimbatoreCoimbatore
PurposePurpose
A significant percentage of fungal isolates recovered from A significant percentage of fungal isolates recovered from keratitis patients fail to sporulate by standard laboratory keratitis patients fail to sporulate by standard laboratory methods.methods.
This group may consists of established ocular pathogens This group may consists of established ocular pathogens which behave differently due to unknown reasons and very which behave differently due to unknown reasons and very rare or newer species.rare or newer species.
This study analyzes whether keratitis caused by non This study analyzes whether keratitis caused by non sporulating filamentous fungi whose species could not be sporulating filamentous fungi whose species could not be identified, differ in clinical features and response to standard identified, differ in clinical features and response to standard antifungal treatment from that caused by species identified antifungal treatment from that caused by species identified dematiaceous and hyaline fungi. dematiaceous and hyaline fungi.
MethodsMethods
A retrospective analysis of data collected from case records of culture A retrospective analysis of data collected from case records of culture proven mycotic keratitis between January 2007 December 2008 to assess proven mycotic keratitis between January 2007 December 2008 to assess
- The incidence of NSM keratitis- The incidence of NSM keratitis
- The casual relationship between trauma, injuring agents and previous - The casual relationship between trauma, injuring agents and previous treatmenttreatment
- Presenting clinical features and response to standard treatment in - Presenting clinical features and response to standard treatment in comparison to those of species identified fungal isolatescomparison to those of species identified fungal isolates
Multiple logistic regression analysis was used to find the casual Multiple logistic regression analysis was used to find the casual relationship to non-sporulation and associated clinical features and relationship to non-sporulation and associated clinical features and response to therapy was analyzed by Pearson Chi – Squareresponse to therapy was analyzed by Pearson Chi – Square
Species Identified & Unidentified by Species Identified & Unidentified by sporesspores
Dematiaceous Dematiaceous FreqFreq--------------------------------------------------------------------NSDM (non sporing) NSDM (non sporing) 2020Curvularia Curvularia 14 14 Bipolaris Bipolaris 1919Alternaria Alternaria 7 7Cladosporium Cladosporium 4 4 Collectotrichium Collectotrichium 3 3Exerohilum Exerohilum 8 8Lasidiplodia Lasidiplodia 5 5 Nigrosporen Nigrosporen 2 2Aureobasidum Aureobasidum 1 1 Exophila Exophila 1 1-----------------+------------------- -----------------+------------------- TotalTotal 8484
Hyaline Hyaline Freq. Freq. --------------------------------------------------------------------------------NSHM ( non-sporing) NSHM ( non-sporing) 87 87 Fusarium Fusarium 237 237 Aspergillus Aspergillus 81 81 Neocosmospora Neocosmospora 1 1 Pencilium Pencilium 4 4 Scedosporium Scedosporium 2 2Trichothesium Trichothesium 2 2--------------+------------------------- --------------+------------------------- Total Total 414414
Colony morphology on the solid mediumColony morphology on the solid medium
Aspergillus Flavus Aspergillus Flavus Fusarium semitectumFusarium semitectum
Spore morphologySpore morphology
A.Flavus A.Flavus Fusarium semitectumFusarium semitectum
Slide culture LPCB Slide culture LPCB
Results - IncidenceResults - Incidence125, 21%
469, 79%
NSM
SM
FUNGUSFUNGUS FREQFREQ PERCENTPERCENT
NSMNSM 125125 21.0421.04
SMSM 469469 78.9678.96
TotalTotal 594594 100100
ISOLATESISOLATES FRQUFRQU PERCENTPERCENT
NSDMNSDM 2323 22.5522.55
SDMSDM 7979 77.4577.45
TotalTotal 102102 100100
23, 23%
79, 77%
NSDM
SDM
IsolatesIsolates FreqFreq PercentPercent
NSHMNSHM 102102 20.8620.86
SHMSHM 387387 79.1479.14
TotalTotal 489489 100100387, 79%
102, 21%
NSHM
SHM
NSM-nonsporing mold,SM-sporing mold, NSDM-non-sporing dematiaceus, NSHM-Nonsporing Hyaline
Causative clinical factors for non-sporulationCausative clinical factors for non-sporulation
Variable Uni variate Multivariate
OR (95% CI) P-value OR (95% CI) P-value
Injury with veg-mater 0.69 (0.45 – 1.08) 0.105 0.47 (0.14 – 1.57) 0.220
Injury with nonveg-mater 1.19 (0.74 – 1.92) 0.474 0.71 (0.22 – 2.24) 0.554
No injury 1.10 (0.73 – 1.66) 0.654 0.64 (0.20 – 2.02) 0.441
Injury with unknown object 1.11 (0.50 – 2.48) 0.791 0.78 (0.26 – 2.34) 0.662
Superficial plaques 0.94 (0.56 – 1.59) 0.816 0.70 (0.34 – 1.42) 0.320
Feathery edged infiltrates 1.02 (0.64 – 1.60) 0.945 0.72 (0.35 – 1.47) 0.361
Full thockness abscess 0.80 (0.48 – 1.33) 0.389 0.77 (0.37 – 1.58) 0.471
Endothelial plaque 0.87 (0.52 – 1.45) 0.592 1.23 (0.68 – 2.22) 0.493
Hypopyon 0.66 (0.44 – 0.99) 0.047 0.68 (0.42 – 1.07) 0.098
Perforated ulcer 0.94 (0.30 – 2.90) 0.909 0.75 (0.21 – 2.61) 0.646
Antifungal 0.79 (0.53 – 1.21) 0.287 0.88 (0.54 – 1.42) 0.594
Antibiotic 1.08 (0.70 – 1.67) 0.724 1.22 (0.75 – 2.00) 0.422
Time lag before treatment 0.69 (0.46 – 1.05) 0.08 0.74 (0.48 – 1.16) 0.188
There is no casual There is no casual relationship between relationship between trauma, injuring trauma, injuring agents and previous agents and previous treatmenttreatment
Multiple logistic Multiple logistic regression analysis of regression analysis of these features, time these features, time lag before lag before consultation and consultation and clinical features also clinical features also failed to show any failed to show any significancesignificance
Multiple Logistic Regression - Presenting Clinical Multiple Logistic Regression - Presenting Clinical FeaturesFeatures
Non-Sporing & Sporing Hyaline molds
Non-Sporing & SporingNon-Sporing & Sporing Dematiaceous Dematiaceous Molds Molds
In non-sporulating dematiaceous group hypopyon was significantly a rare presentation (P-In non-sporulating dematiaceous group hypopyon was significantly a rare presentation (P-0.003, OR 0.197 95 CI 0.067-0.579). Among hyaline fungi there was no difference in clinical 0.003, OR 0.197 95 CI 0.067-0.579). Among hyaline fungi there was no difference in clinical featuresfeatures
Response to Antifungal treatmentResponse to Antifungal treatmentHEALED
368 70.0
158 30.0
526 100.0
Healing
Non Healing
Total
Frequency Percent
Crosstab
Count
12 8 20
58 13 71
70 21 91
UID
Demataceous Fungi
UID - DemataceousFungus
Total
Healing Non Healing
HEALED
Total
UID - Dematiaceous Fungus HEALED ( P value – 0.042 )
*Unidentified demateaceous (NSDM)
* UIH - Hyaline Fungus HEALED ( P value – 0.294 )
Crosstab
Count
58 33 91
237 104 341
295 137 432
UIH
Hyaline Fungi
UIH - HyalineFungus
Total
Healing Non Healing
HEALED
Total
* Unidentified Hyaline (NSHM)
Nonsporing Dematiaceous responded relatively better to therapy Nonsporing Hyaline molds responded similar to other hyaline fungi
Discussion Discussion
Non-sporulating filamentous fungi constitute Non-sporulating filamentous fungi constitute significant percentage among keratitis pathogens significant percentage among keratitis pathogens
No clinically significant causative factor for non-No clinically significant causative factor for non-sporulation was found sporulation was found
Non-sporulating dematiaceous group presented rarely Non-sporulating dematiaceous group presented rarely with hypopyon and healed better with hypopyon and healed better
But hyaline fungi did not showed any difference in But hyaline fungi did not showed any difference in presentation and outcomepresentation and outcome
ConclusionConclusion
Non-sporing ocular fungal pathogens constitute an Non-sporing ocular fungal pathogens constitute an interesting area of researchinteresting area of research
Polymerase Chain Reaction based DNA sequencing Polymerase Chain Reaction based DNA sequencing of the ocular fungal isolates identified some newer of the ocular fungal isolates identified some newer emerging pathogens in addition to established onesemerging pathogens in addition to established ones
The reason for their non-sporing nature is not clearThe reason for their non-sporing nature is not clear Their sensitivity to the existing antifungal agents is Their sensitivity to the existing antifungal agents is
yet to be studiedyet to be studied Clinically they behave almost similar to the Clinically they behave almost similar to the
established filamentous fungiestablished filamentous fungi
ReferencesReferences
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La´szlo´ Kredics, Ja´nos Varga, Sa´ndor Kocsube´, Revathi Rajaraman et al, Infectious Keratitis Caused by Aspergillus tubingensis. Cornea. 2009 Sep;28(8):951-4
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