Corneal co-infection with Scedosporium apiospermum and Acanthamoeba after sewage-contaminated ocular injury

Purpose. To describe a corneal co-infection with the fungus Scedosporium ap iospermum and Acanthamoeba that result in spontaneous corneal perforation. Methods. A 27-year-old man presented due to severe ocular pain in his left eye caused by a corneal ulcer. The patient was injured 7 days before presen tation by metallic thread contaminated by sewage. Corneal scrapping and dee p stromal biopsy were obtained and stained for microscopic evaluation with periodic acid-Schiff, Giemsa, and Gomori's methenamine silver stains. Sampl es were sent for aerobic and anaerobic bacterial and fungal cultures. Resul ts. Corneal biopsy and corneal scrapping showed viable Acanthamoeba cysts i n the corneal stroma and S. apiospermum micelle, respectively. The fungal c ulture was sensitive to ketoconazole, miconazole, econasole, and traconazol e. Devastating corneal perforation occurred despite aggressive antifungal a nd antiamoebic topical and systemic treatment initiated after diagnosis. Th e corneal button showed a necrotic tissue devoid of inflammatory cells and microorganisms. Conclusion. S. apiospermum and Acanthamoeba may co-infect i mmune privilege sites, such as the cornea, in immunocompetent hosts. Compro mised corneal surface, e.g., after trauma by sewage-contaminated objects, m ay increase the susceptibility for such devastating coinfection. Prevention may be possible by use of protective eyewear by high-risk individuals. Tre atment should be initiated promptly with broad-spectrum antimicrobial agent s after ocular injury by sewage-contaminated objects. Repeated corneal cult ures and biopsies, if the cultures are negative, are warranted. Corticoster oids should be withheld until the causative agents are identified and targe ted treatment is initiated.