title: Voriconazole in the management of Alternaria keratitis.
abstract: OBJECTIVE
  To discuss the role of voriconazole in the management of Alternaria keratitis.
  
  
  METHODS
  Case report and literature review.
  
  
  RESULTS
  A 69-year-old man with a history of corneal foreign body removal developed a stromal infiltrate 2 months later that did not improve despite topical antibiotics and natamycin. On our initial examination, visual acuity (VA) was 20/40, and he had a central, full-thickness, reticular appearing infiltrate. Oral clarithromycin was added because of the atypical pattern of the infiltrate. However, no improvement was noted. A repeat culture revealed coagulase-negative Staphylococcus. VA decreased to 20/200, and increased inflammation was noted a month later; a trial of topical steroids was added. After an initial improvement, he returned with progression. Repeat culture revealed Alternaria species, and topical amphotericin was started. When there was no response, he was admitted and switched to oral and topical voriconazole. Steady resolution was noted within 10 days of therapy.
  
  
  CONCLUSIONS
  Suspicion must be maintained for unusual causes of infectious keratitis. Fungal infection can be difficult to eradicate even with traditional antifungals. Although not approved for ophthalmic use yet, voriconazole provided improvement with Alternaria keratitis unresponsive to amphotericin.
authors.affiliation: Cornea Service, Wills Eye Hospital, Philadelphia, Pennsylvania 19107, USA.
authors.forename: Zeynep
authors.initials: Z
authors.lastname: Ozbek
authors.forename: Sheila
authors.initials: S
authors.lastname: Kang
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Sivalingam
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Rapuano
authors.forename: Elisabeth J
authors.initials: EJ
authors.lastname: Cohen
authors.forename: Kristin M
authors.initials: KM
authors.lastname: Hammersmith
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000528:Alternaria / Q000302:isolation & purification*; D000935:Antifungal Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D003315:Cornea / Q000382:microbiology* / Q000473:pathology; D003937:Diagnosis, Differential; D015821:Eye Infections, Fungal / Q000188:drug therapy* / Q000382:microbiology / Q000473:pathology; D005500:Follow-Up Studies; D006801:Humans; D007634:Keratitis / Q000188:drug therapy* / Q000382:microbiology / Q000473:pathology; D008297:Male; D009883:Ophthalmic Solutions; D011743:Pyrimidines / Q000008:administration & dosage / Q000627:therapeutic use*; D014230:Triazoles / Q000008:administration & dosage / Q000627:therapeutic use*; D065819:Voriconazole
chemical_list: D000935:Antifungal Agents; D009883:Ophthalmic Solutions; D011743:Pyrimidines; D014230:Triazoles; D065819:Voriconazole