Purpureocillium lilacinum Keratitis and Endophthalmitis in an Aphakic Eye With Secondary Glaucoma: A Case Report

TL;DR

A rare fungal infection in the eye caused severe vision loss and required surgical removal despite treatment.

Contribution

This case report highlights the diagnostic and therapeutic challenges of Purpureocillium lilacinum keratitis in a patient with a history of ocular trauma.

Findings

P. lilacinum keratitis is difficult to diagnose and resistant to standard antifungal treatments.

Voriconazole showed the best efficacy, but vision loss was irreversible once deep stromal invasion occurred.

Repeated cultures were necessary to confirm the diagnosis, as initial samples were negative.

Abstract

Purpureocillium lilacinum(formerly Paecilomyces lilacinus) is a rare filamentous fungus that can cause keratitis in eyes with predisposing factors such as chronic ocular surface disease, previous surgery, trauma, or long-term use of topical steroids. This infection often exhibits resistance to standard antifungal agents and can result in severe visual loss. We report a case of keratitis combined with endophthalmitis in a male patient under 60 years of age with a history of childhood ocular trauma leading to aphakia and secondary glaucoma of the right eye. The patient had undergone several previous interventions, including cyclocryotherapy for glaucoma control. He presented with progressive corneal whitening, pain, and marked vision loss. On admission, the right eye showed a dense central corneal ulcer with full-thickness stromal infiltration, hypopyon, and vitreous opacities. The cornea was opaque, preventing a clear view of the anterior chamber or fundus. The first corneal swab showed no microbial growth. Subsequent cultures of conjunctival and corneal swabs yielded P. lilacinum. Intensive topical and systemic therapy with voriconazole, natamycin, vancomycin, and ceftazidime was initiated. Enucleation was recommended due to pain, poor prognosis, and early signs of phthisis on ocular B-scan, but the patient initially refused. The eye remained anatomically intact but functionally blind. At a later emergency follow-up, enucleation was eventually accepted. P. lilacinum keratitis is challenging to diagnose and manage because of its resistance to amphotericin B and natamycin. Voriconazole demonstrates the greatest efficacy, but visual prognosis is often poor once deep stromal invasion occurs. Repeated cultures may be necessary for diagnosis, as initial samples may show no growth. Early antifungal therapy and clear communication with the patient are essential. This case illustrates the therapeutic challenges of P. lilacinum keratitis and the rapid progression of the disease despite treatment. Even with appropriate antifungal therapy, structural damage and vision loss may be irreversible. Early microbiological diagnosis and honest discussion with the patient regarding the poor prognosis are critical.

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