LAUSR

Dear Editor, Polymicrobial keratit is could constitute a more sight-threatening condition than monomicrobial keratitis because microbial pathogenicity is augmented and therefore resistant to antimicrobial agents [1]. Triple infection keratitis indicates simultaneous infection by three different pathogens; however, few related cases of corneal cross-linking and severe ocular surface disease have been reported [2,3]. Here, we describe a catastrophic clinical course of simultaneous triple microbial keratitis, and the missed opportunity for ocular preservation because the possibility of simultaneous infection was neglected. A 71-year-old male patient was referred to our hospital complaining of aggravated keratitis despite vigorous antimicrobial treatment. He had a history of diabetes and had experienced a foreign body sensation in his right eye for 1 week. He was initially treated in a local eye clinic: 0.5% moxif loxacin eye drops (Vigamox, Norvatis AG, Basel, Switzerland) were administered every 2 hours but were ineffective. He was referred to a local general hospital, and the smear and culture of a corneal scrape performed at that hospital were negative. A combination of fortified ceftazidime and fortified voriconazole eye drops was administered hourly because the causative microbe was unknown. Finally, he was referred to our hospital because a hypopyon was present with aggravated infiltration and pain. Upon presentation, right-eye visual acuity was only hand motion, and a 6.5 × 6.0-mm-sized central infiltration of a feathery margin with 1.0-mm hypopyon was observed. Tiny scattered satellite infiltrates were also identified (Fig. 1A). Corneal scraping was performed at two sites. Empirical fortified 5% vancomycin (Hanomycin injection; SamJin Pharma, Seoul, Korea), 5% ceftazidime (Tazime injection; Hanmi, Seoul, Korea), and 0.15% amphotericin B (f-AMB) were administered every 10 minutes initially and then tapered to every 2 hours over a period of 6 hours. At 2 days postadmission, initial culture revealed Streptococcus salivarius. At 4 days postadmission, the hypopyon had nearly disappeared, and ocular pain had improved (Fig. 1B); therefore, we tapered f-AMB because we suspected that fungal coverage was not needed. Beginning at 6 days postadmission, the hypopyon and corneal infiltration were slightly aggravated (Fig. 1C). We suspected superinfection or coinfection by another microbe; therefore, we performed another corneal scraping and administered f-AMB. The second culture revealed Staphylococcus cohnii subspecies Urealyticum at 8 days postadmission; concurrently, loading doses of fortified vancomycin and intravitreal voriconazole injection (100 μg/0.1 mL; Vfend, Pfizer, New York, NY, USA) were administered (Fig. 1D). These therapies were unsuccessful, and therapeutic penetrating keratoplasty with a corneal biopsy was performed at 11 days postadmission. Periodic acid-Schiff and Gomori methenamine-silver nitrate staining revealed numerous hyphae with branching on corneal biopsy, indicating Fusarium Korean J Ophthalmol 2019;33(6):573-574 ht tps: / /doi.org /10.3341/k jo.2019.0032