Contact-Lens-Associated Purpureocillium Keratitis: Risk Factors, Microbiologic Characteristics, Clinical Course, and Outcomes

ABSTRACT<i>Purpose</i>: To study the risk factors, microbiologic characteristics, clinical course, and outcomes of patients with Purpureocillium keratitis at a tertiary eye care center in south Florida. <i>Materials and Methods</i>: All medical records during a seven-year period starting January 1, 2007, were reviewed. Twenty-eight culture-proven Purpureocillium keratitis cases with complete medical records presenting to our institution were included in this retrospective, observational case series. Data collected included predisposing factors, therapeutic interventions, treatment duration, and visual outcomes. <i>Results</i>: Twenty patients (71.4%) had a history of soft contact lens use, with only two for therapeutic use. Other identified risk factors were trauma and immunosuppression. Fifteen patients (53.6%) received topical corticosteroid treatment prior to the diagnosis of fungal keratitis. Thirteen patients (46.4%) were on Natamycin treatment prior to Purpureocillium identification. As a group, the average best-corrected visual acuity (BCVA) at presentation was 1.1 logMAR; upon the final evaluation, it was 1.0 logMAR. The BCVA on last evaluation for the eight patients presenting to our institution within two weeks of onset of symptoms was 0.3 log MAR, and all patients in this group responded to medical management. The final BCVA for 20 patients presenting two weeks after onset of symptoms was 1.2 logMAR. There was a significant difference in the final BCVA between Group 1 and Group 2 (<i>p</i> = 0.004), but no difference in steroid use or previous treatments. Previous steroid use tended to extend time to presentation and was significantly associated with a worse final visual outcome (1.2 versus 0.6 logMAR; <i>p</i> = 0.0474). Previous Natamycin use was significantly associated with a worse final visual outcome (1.4 versus 0.6 logMAR; <i>p</i> = 0.014). <i>Conclusion</i>: Purpureocillium keratitis can have devastating consequences to visual function and even lead to enucleation. Physicians should make every effort to arrive at an earlier microbiological diagnosis, as this is associated with better outcomes and less need for surgical intervention. The first line use of voriconazole is recommended, and steroid use should be avoided, as their previous use is associated with worse visual outcomes.

**摘要**
**研究目的**：旨在探究佛罗里达州南部某三级眼科医疗中心收治的紫色拟青霉角膜炎（Purpureocillium keratitis）患者的危险因素、微生物学特征、临床病程及预后转归。
**材料与方法**：回顾分析2007年1月1日起七年时限内的全部医疗档案，纳入本机构收治的28例经微生物培养确诊且病历资料完整的紫色拟青霉角膜炎病例，开展回顾性观察性病例系列研究。收集的研究数据包括易感危险因素、治疗干预方案、治疗周期及视觉预后指标。
**结果**：20例患者（71.4%）存在软性角膜接触镜佩戴史，其中仅2例为治疗性佩戴。其余明确的危险因素包括眼部外伤与免疫抑制状态。15例患者（53.6%）在确诊真菌性角膜炎前曾接受局部糖皮质激素治疗，13例患者（46.4%）在明确紫色拟青霉感染前曾使用那他霉素（Natamycin）治疗。整体队列中，患者初诊时的平均最佳矫正视力（best-corrected visual acuity, BCVA）为1.1 logMAR，末次随访时平均BCVA为1.0 logMAR。其中，症状发作两周内就诊的8例患者，其末次随访BCVA为0.3 logMAR，且该组全部患者均对药物治疗产生应答。症状发作两周后就诊的20例患者，其末次随访BCVA为1.2 logMAR。两组患者的末次BCVA存在显著统计学差异（P=0.004），但在糖皮质激素使用史或既往治疗方案上无显著差异。既往糖皮质激素使用史往往会延迟患者就诊时间，且与更差的最终视觉预后相关（两组最终BCVA分别为1.2与0.6 logMAR；P=0.0474）。既往使用那他霉素同样与更差的最终视觉预后显著相关（两组最终BCVA分别为1.4与0.6 logMAR；P=0.014）。
**结论**：紫色拟青霉角膜炎可对视觉功能造成毁灭性损害，甚至可导致眼球摘除。临床医师应尽力尽早明确微生物学诊断，此举可改善患者预后、降低手术干预需求。推荐将伏立康唑（voriconazole）作为一线治疗药物，且应避免使用糖皮质激素，因既往糖皮质激素使用与更差的视觉预后显著相关。