Rhodotorula Keratitis: A Rarely Encountered Ocular Pathogen

Purpose: To describe a case of fungal keratitis involving an atypical organism with confirmatory in vivo confocal microscopy and to review the literature on Rhodotorula keratitis. Methods: Case report and review of the medical literature. Results: A 22-year-old college student was struck in the left eye with a tree branch and subsequently developed pain, redness and photophobia. Upon presentation, visual acuity was 20/200 and there was a large epithelial defect with diffuse stromal inflammation involving the anterior one-third of the cornea. Cultures of the infiltrate were performed for bacterial, viral and fungal organisms that resulted in a positive culture for Rhodotorula mucilaginosa. Fungal elements were confirmed in vivo by confocal microscopy. The patient was treated with voriconazole initially and had amphotericin added once Rhodotorula infection was confirmed. The patient responded well clinically, and one month after therapy was initiated, the corneal infiltrate had resolved leaving mild anterior stromal haze. Upon completion of therapy at three months, the patient was asymptomatic, had a clear cornea and had a best corrected visual acuity of 20/20 in the involved eye. There was no measurable change in his manifest refraction. Conclusions: Prior cases of Rhodotorula keratitis most often required surgical intervention and were associated with poor outcomes. This case shows that Rhodotorula keratitis can be successfully treated with topical antifungal agents if diagnosed early and appropriate treatment is initiated promptly. We report the first case of Rhodotorula keratitis confirmed by in vivo confocal microscopy. This is also the first description of pseudomycelium formation that has not been previously described in vivo, a morphological structure that this organism rarely demonstrates. Finally, this case shows that confocal microscopy may aid in the early diagnosis and management of fungal keratitis involving this rare but potentially damaging organism.