title: A super-infection in the cornea caused by Stemphylium, Acremonium, and α-Streptococcus.
abstract: BACKGROUND
  Polymicrobial keratitis with fungus and bacteria can lead to blindness and is challenging to treat. Here, we introduce a case of fungal keratitis caused by two different strains in addition to definite bacterial super-infection caused by an α-Streptococcus sp., and describe the importance of microscopic examination.
  
  
  METHODS
  A 74-year-old woman, who had a past history of infection with leprosy, presented with conjunctival hyperaemia, pain, and corneal opacity in her right eye. Under the presumptive diagnosis of infectious keratitis, corneal scrapings were stained by various reagents and inoculated on several agar plates. Microscopic findings of the scrapings revealed fungi and a small number of Gram-positive cocci. Multiple anti-fungal therapies with levofloxacin ophthalmic solution were administered. Although empiric treatment was initially effective, keratitis recurred 10 days after its initiation. Repeated corneal scraping revealed an abundance of Gram-positive chain cocci and a small amount of fungi, resulting in the switching of an antibiotic medication from levofloxacin to moxifloxacin and cefmenoxime. Keratitis resolved gradually after the conversion. Stemphylium sp., Acremonium sp., and α-Streptococcus sp. were simultaneously isolated from the corneal scrapings.
  
  
  CONCLUSIONS
  To the best of our knowledge, this is the first case of fungal keratitis caused by Stemphylium sp., and also the first case of super-infection in the cornea caused by two different fungi and one bacterium. Microscopic examination of the corneal scrapings was beneficial in rapid decision of changing to appropriate drug according to the dominancy of pathogenicity.
authors.affiliation: Department of Ophthalmology, Sakai Hospital Kindai University, 2-7-1 Harayamadai, Minami-ku, Sakai, Osaka, 590-0132, Japan.
authors.forename: Fumika
authors.initials: F
authors.lastname: Hotta
authors.affiliation: Department of Ophthalmology, Sakai Hospital Kindai University, 2-7-1 Harayamadai, Minami-ku, Sakai, Osaka, 590-0132, Japan. hiroegu0113@gmail.com.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Eguchi
authors.affiliation: Department of Ophthalmology, Shikoku Medical Center for Children and Adults, 2-1-1 Senyu-cho, Zentsuji, Kagawa, 765-8507, Japan.
authors.forename: Keiko
authors.initials: K
authors.lastname: Nishimura
authors.affiliation: Department of Ophthalmology, Shikoku Medical Center for Children and Adults, 2-1-1 Senyu-cho, Zentsuji, Kagawa, 765-8507, Japan.
authors.forename: Masahiro
authors.initials: M
authors.lastname: Kogiso
authors.affiliation: Department of Ophthalmology, Shikoku Medical Center for Children and Adults, 2-1-1 Senyu-cho, Zentsuji, Kagawa, 765-8507, Japan.
authors.forename: Mayumi
authors.initials: M
authors.lastname: Ishimaru
authors.affiliation: Department of Ophthalmology, Sakai Hospital Kindai University, 2-7-1 Harayamadai, Minami-ku, Sakai, Osaka, 590-0132, Japan.
authors.forename: Shunji
authors.initials: S
authors.lastname: Kusaka
authors.affiliation: Department of Ophthalmology, Kindai University Hospital, 377-2 Ohnohigashi, Osakasayama, Osaka, 589-8511, Japan.
authors.forename: Yoshikazu
authors.initials: Y
authors.lastname: Shimomura
authors.affiliation: Medical Mycology Research Center, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8673, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Yaguchi
mesh_terms: D000164:Acremonium / Q000187:drug effects / Q000254:growth & development* / Q000472:pathogenicity; D000368:Aged; D000890:Anti-Infective Agents / Q000627:therapeutic use; D015281:Cefmenoxime / Q000627:therapeutic use; D060085:Coinfection / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology / Q000473:pathology; D003315:Cornea / Q000187:drug effects / Q000382:microbiology / Q000473:pathology; D015821:Eye Infections, Fungal / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology / Q000473:pathology; D005260:Female; D024841:Fluoroquinolones / Q000627:therapeutic use; D006801:Humans; D007634:Keratitis / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology / Q000473:pathology; D064704:Levofloxacin / Q000627:therapeutic use; D000077266:Moxifloxacin; D004718:Saccharomycetales / Q000187:drug effects / Q000254:growth & development* / Q000472:pathogenicity; D013291:Streptococcus / Q000187:drug effects / Q000254:growth & development* / Q000472:pathogenicity
chemical_list: D000890:Anti-Infective Agents; D024841:Fluoroquinolones; D064704:Levofloxacin; D015281:Cefmenoxime; D000077266:Moxifloxacin
keywords: Acremonium; Keratitis; Microscopic examination; Pathogenicity; Stemphylium; Super-infection; α-Streptococcus