Topical voriconazole therapy of Purpureocillium lilacinum keratitis that occurred in disposable soft contact lens wearers

The objective of this study was to describe 2 cases of keratitis caused by Purpureocillium lilacinum (formerly Paecilomyces lilacinus) that occurred in disposable contact lens users, which were successfully treated with topical voriconazole. Case 1 was a healthy 44-year-old woman, who wore weekly disposable contact lenses and had developed a superficial corneal infection in her right eye. For diagnosis, corneal scraping and molecular identification of the cultured pathogen were performed. A corneal smear revealed the presence of fungi. The pathogen was identified as P. lilacinum by traditional morphological identification of fungal culture, and this identification was confirmed by DNA sequencing of the ribosomal internal transcribed spacer (ITS) sequence. Therapy with topical fluconazole, topical pimaricin (natamycin), and oral itraconazole were ineffective. Topical voriconazole showed a significant effect, and the keratitis was successfully treated. Case 2 was a 43-year-old woman with bilateral recurrent peripheral corneal ulcers by meibomian gland dysfunction, who used therapeutic bandage contact lenses on her left eye. However, a corneal abscess with hypopyon occurred in the eye after 3 months. The microbial smear examination showed the presence of fungi and the fungal culture, and the DNA sequence of ITS region revealed that the causative agent was P. lilacinum. The susceptibility testing against antifungal agents showed that voriconazole was effective. The lesion improved gradually by topical voriconazole. As a conclusion, P. lilacinum keratitis can occur in disposable soft contact lens wearer. Early and accurate detection of the pathogenic organism is essential. Topical voriconazole was effective against P. lilacinum keratitis.