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Successful Treatment of Paecilomyces lilacinus Keratitis With Oral Posaconazole

Arnoldner, Michael A. MD*; Kheirkhah, Ahmad MD*,†; Jakobiec, Frederick A. MD, DSc; Durand, Marlene L. MD§; Hamrah, Pedram MD*,†

doi: 10.1097/ICO.0000000000000143
Case Report

Purpose: To report a case of successful medical treatment with oral posaconazole in refractory fungal keratitis caused by Paecilomyces lilacinus.

Methods: Case report.

Results: A 57-year-old male, soft contact lens wearer presented with irritation, pain, photophobia, and reduced vision. Slit-lamp examination showed a large corneal epithelial defect with a peripheral infiltrate. The patient did not improve on fortified topical antibiotics. After the diagnosis of P. lilacinus fungal keratitis, oral voriconazole and topical antifungal therapy were started. Despite antifungal therapy, progressive disease required therapeutic penetrating keratoplasty. Postoperatively, because of clinical signs of recurrence and in vivo confocal microscopy findings of presumed hyphae in the cornea, intracameral miconazole was injected and oral posaconazole was started. The patient improved and demonstrated no hyphae 6 weeks after starting posaconazole. When posaconazole was stopped, the cornea remained clear with excellent acuity. However, because of acute graft rejection 2 months after stopping posaconazole, keratoprosthesis was implanted, with no evidence of infection at surgery or during the 3.5-year follow-up.

Conclusions: To the best of our knowledge, this is the first report on the use of oral posaconazole for Paecilomyces keratitis. Posaconazole might be indicated in the treatment of refractory Paecilomyces keratitis that is resistant to conventional therapy.

*Ocular Surface Imaging Center, Massachusetts Eye and Ear Infirmary, Boston, MA;

Corneal and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA;

Department of Ophthalmology, Cogan Pathology Laboratory, Massachusetts Eye and Ear Infirmary, Boston, MA; and

§Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Reprints: Pedram Hamrah, MD, Cornea Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114 (e-mail: pedram_hamrah@meei.harvard.edu).

Supported by NIH K08-EY020575, NIH K12-EY016335, New England corneal transplant research fund, and Falk Medical Research Foundation (P.H.).

The other authors have no other funding or conflicts of interest to disclose.

Received January 06, 2014

Accepted March 27, 2014

© 2014 by Lippincott Williams & Wilkins.