Brit. J. Ophthal. (1975) 599 47

Keratomycosis in Lucknow

R. L. KOUL AND V. B. PRATAPDepartment ofOphthalmology, K.G's Medical College, Lucknow, India

Virchow first introduced the term mycosis forfungal infections. Leber (I 870) first described a caseofkeratomycosis due to Aspergillus and first establishedan early clinical diagnosis by mycological methods.Since his report more than thirty species of saprophyticfungi have been identified as causative agents ofkeratomycosis. A review of the literature for the last20 years shows an increase in the incidence of fungalinfections all over the world (Chick and Conant,I 962; Gingrich and Pinkerton, I 962). Nauman, Green,and Zimmerman (i 967) reported a 1s-fold increase infungal infection. Agarwal and Khosla (i963) reportedsix cases, whereas Mitsui and Hanabusa (I955) hadreported only four.Having recently encountered cases ofcorneal ulcers

which were resistant to the usual antibiotic and sup-portive therapy and showed a tendency to progress,we undertook mycological studies to find out the roleof normal existing saprophytic fungi in the conjunc-tival flora in such ulcers.

Material and methods

Seventy cases of corneal ulcers seen at the Ghandhi Mem-orial and Associated Hospitals, Lucknow, were includedin the study. The following points were noted:

(a) Age, place of residence, and socioeconomlic statusof patient;(b) History oftrauma or local use ofany drug;(c) Detailed examination ofthe corneal ulcer.

For the collection of smears and mycological studyscrapings from the ulcer margin were taken on sterilizedswab sticks and then introduced aseptically into Sabour-aud's agar slants to which chloramphenicol (o.os percent.) had been added to inhibit bacteria. A sterilized VonGraefes knife was used for taking scrapings from thedeeper parts of the ulcer margins. For the bacterial study,scrapings were inoculated into nutrient agar slants usingsimilar techniques.

Sabouraud's agar slants after inoculation were incu-bated at 280 C. for at least io days. Further isolation andstudy of the fungi in pure culture was done on Sabouraud's

Address for reprints: Dr. V. B. Pratap, Department of Ophthal-mology, K.G.'s Medical College, Lucknow, 226003, India.

and Czapek Dox agar media. Bacterial cultures wereexamined after 24 to 48 hrs' incubation at 370 C. and thebacteria were isolated in pure culture on blood agarplates. Fungi were stained in lactophenol cotton blue formicroscopic examination.

Results

Fungi were isolated from 22 of the seventy speci-mens. In six cases fungi were the sole micro-organismsdetected by culture and staining. In others both bac-teria and fungi were detected. Table I shows the clini-cal picture of eleven cases, showing fungi alone (3) ormixed with bacteria (8).

Table I Clinical findings in II cases

Caseno. Clinical picture Micro-organisms

I Sloughing corneal ulcer withhypopyon Fungi + bacteria

2 Ring-shaped corneal ulcer withhypopyon Fungi

3 Central corneal ulcer withhypopyon; clear-cut margins Fungi + bacteria

4 Central corneal ulcer withhypopyon Fungi + bacteria

5 Perforated corneal ulcer Fungi + bacteria6 Central corneal ulcer Fungi + bacteria7 Sloughing corneal ulcer on verge

of perforation Fungi8 Spreading corneal ulcer with

dirty margin Fungi + bacteria9 Spreading corneal ulcer with

dirty base with hypopyon Fungi + bacteriaIO Ring-shaped ulcer with clear

periphery with hypopyon FungiI I Central corneal ulcer with

hypopyon Fungi + bacteria

Fourteen patients had hypopyon; ten of these hadmixed infection and four had only fungus with ringformation. The other patients in which fungus wasthe sole micro-organism detected were first seen with

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an almost complete sloughing ulcer on the verge ofperforation. These observations suggest that one maysuspect fungus infection in an ulcer presenting with aring formation.The incidence of infection was less in the patients

in the lower and higher age groups (Table II).

Table II Micro-organismsfrom 70patientsofdifferentagegroups

Age in decadesMicro-organism

Ist 2nd 3rd 4th 5th 6th Total

Bacteria only 4 6 i6 8 IO 4 48Bacteria and 2 2 4 8 - - x6

fungiFungi only - 4 - - 2 - 6

Total 6 12 20 i6 I2 4 70

Fungi were isolated more frequently from malethan from female patients (Table III).

Table IIIpatien ts

Micro-organismsfrom male andfemale

Sex Bacteria andfungi Fungi Total

Male I0 4 14Female 6 2 8

Total I6 6 22

Patients from urban areas showed a greater inci-dence of fungi either alone or mixed with bacteria,although more cases of corneal ulcers came from ruralareas (Table IV).

Table IV Incidence ofinfection inpatientsfrom rural andurban areas

Micro-organisms Rural Urban Total

Fungi and bacteria 4 I2 I6Fungi 2 4 6

Total 6 I6 22

TableV Micro-organisms isolatedfrom 22 cases

Micro-organisms

Aspergillus nidulans, A. niger, Actinomycetes+bacteria

Hormodendrum sp.Penicillium sp. +bacteriaA.fumigatus+ bacteriaA.terreus, A.glaucus+ bacteriaScopulariopsis sp.+ bacteriaAspergillusfumigatusHornodendrum sp., A.niger+ bacteriaA.terreus+ bacteriaA.nididans,4.flavus oryzae, Actinomycetes+ bacteria

No. of cases

2

42I

3I

223

Discussion

Although most of the fungi could be cultured easilywithin a period of 2 weeks, Hormodendrum, which wasisolated singly in a case of corneal ulcer, took anunusually long time, about IO weeks, to grow. Of thevarious fungi found in the present study, species ofAspergillus, Homodendrum, and Scopulariopsis, as wellas Actinomycetes, were found as normal commensals ofthe conjunctival flora. The fungi most frequentlyisolated in our series were Aspergillus sp. The fungifound as normal commensals may thus play a role inthe pathogenesis of corneal ulcers under changedenvironmental conditions.

Hormodendrum sp., A.fumigatus, and A.nidulans werefound singly, and taking this in conjunction with theclinical picture of corneal ulcer it is obvious that aring ulcer with hypopyon should make one suspectthe presence offungi.

It is of particular interest that multiple fungal andbacterial infection occurred in eight cases and mixedfungal and bacterial infection in a further eight outofa total of 22 cases ofproven fungal infection (TableV).Ten patients gave the history of trauma; four of

these showed fungi and the other six showed bothfungi and bacteria. Sixteen cases gave the history ofusing drugs locally (corticosteroids); fourteen of theseshowed both fungi and bacteria and two showed onlyfungi. Six cases gave a history of trauma as well as ofthe local application of drugs. Trauma and the use ofcorticosteroids thus seem to encourage the develop-ment offungal infection ofthe cornea.

I am grateful to Dr. O.P. Srivastava, Ph.D., Mycologist,Antibiotic Section, Central Drug Research Institute, Luck-now, for helping with the detailed mycological studies.

The different fungi identified from the 22 cases arelisted in TableV and illustrated in Figs i-io.

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Keratomycosis in Lucknow 49

F I G . 3 A.fumigatus

FIG. I A. nidulans

F IG. 2 A. terreus F IG. 4 A. niger

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FIG. 5 A.glaucus FIG. 7 Hormodendrum sp.

FIG. 6 A.flavusoryzae FIG. 8 Penicilliumsp.

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