Nontraumatic Paecilomyces Anterior Segment Infection: A Pathognomonic Clinical Appearance

PURPOSE:The aim of this study was to review a series of consecutive cases of corneal and scleral infection by Paecilomyces spp. and to identify features of clinical presentation and assess treatment modalities. METHODS:This retrospective review of a case series included 22 patients with nontraumatic Paecilomyces anterior segment infections who were seen in a tertiary referral practice. Outcome measures were the number of eyes that were lost and visual acuity in eyes that were saved. RESULTS:Twenty-two patients with Paecilomyces corneal or scleral infection with no significant history of trauma or surgery were identified over a 20-year period. Two distinct clinical presentations were noted with 17 presenting with corneal infection and 5 initially presenting with scleral infection, and all demonstrated a classical endothelial plaque and deep stromal infiltrate. Almost all required single or multiple anterior segment reconstructive surgeries together with systemic and topical antifungal agents. The first 10 patients were treated with amphotericin B, whereas the remaining 12 patients were treated with voriconazole and 21 of 22 patients underwent surgery. Paecilomyces spp. was identified from most intraocular specimens although corneal fungal growth was noted only from deep corneal biopsies or corneal buttons removed during corneal transplantation. Outcomes were better in the last 12 patients treated with voriconazole. CONCLUSIONS:Nontraumatic Paecilomyces anterior segment infection presents with a pathognomonic clinical picture when the cornea is the initial site of infection and later in scleral infections. Early identification and aggressive treatment with extirpative surgery and voriconazole may result in retention of the eye with useful vision.