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Curvularia A Most Common Missed Occulomycosis in Ocular

Trauma

Authors

Dr. Sunay Sudhir Wanmali1, Dr. Neena N. Nagdeo2, Dr. Vilas R.

Thombare3, Dr. Hema Mathurkar4
1
Department of Microbiology, NKPSIMS, Nagpur, India
Email: sunay146@gmail.com
2
Department of Microbiology, NKPSIMS, Nagpur, India
Email: neenagdeo@yahoo.co.in
3
Department of Microbiology, NKPSIMS, Nagpur, India
Email: drvilasthombare@rediffmail.com
4
Department of Microbiology, NKPSIMS, Nagpur, India
Email: hema_mathurkar@rediffmail.com

Corresponding Author
Dr. Sunay Sudhir Wanmali
Department of Microbiology
NKPSIMS, Nagpur, India
Email: sunay146@gmail.com

ABSTRACT
Curvularia keratitis typically presented as superficial feathery infiltration,
rarely with visible pigmentation that gradually became locally suppurative. Smears of
corneal scrapings often disclosed hyphae, and culture media showed dematiaceous
fungal growth within 1 week. Natamycin had excellent in vitro activity and led to clinical
resolution with good vision in most patients with corneal curvulariosis. Curvularia is a
most common oculomycosis isolated in ocular traumas especially when the trauma is
due to wooden or plant materials. Being, a most common laboratory contaminant, the
patience required to maintain aseptic measures in the clinical microbiology laboratories
and identification of the fungus on the basis of microscopic characteristics can help
from not missing the diagnosis of Curvularia like oculomycosis and thus saving the
critical time in management of corneal ulcers.
Keywords- Curvularia, Occulomycosis, Monomorphic.

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1. INTRODUCTION
Fungal infections of the eye are growing threats that have substantial morbidity and
cost . Aspergillus and Fusarium are long recognized as ocular pathogens2, but the
1

dematiaceous hyphomycetes have emerged as important opportunists3,4,5,6. Originally named

for their tufted, floccose appearance in culture, dematiaceous fungi comprise those septate
molds with melanin in their hyphae and conidia7. Curvularia is a prevalent member of these
darkly pigmented fungi that received its current name in 19338 . This genus of filamentous
fungi colonizes soil and vegetation and spreads by airborne spores. Some of the 40
Curvularia species are phytopathogens. Plant diseases range from seedling failure to leaf
blight9, including grass “fade out” during hot, humid weather. Curvularial growth on stored
grain, thatch, and other dead plant material looks like smudges of blackish dust. Several
Curvularia species are zoopathogenic. Wound infection is the most common disease caused
by Curvularia and ranges from onychomycosis to skin ulceration and subcutaneous
mycetoma10,11. Other human Curvularia infections are invasive and allergic sinusitis and
bronchopulmonary disease. Abscesses of the lung, brain, liver, and connective tissue have
occurred. Nosocomial infections include dialysis-related peritonitis and postsurgical
endocarditis12. Infection of the cornea, reported in 195913, was the first human disease proved
to be caused by Curvularia. Other ocular infections consist of conjunctivitis14, dacryocystitis,
sino-orbital cellulitis, and endophthalmitis15,16. But the cornea is the most commonly infected
site2,3,13,14. Some Curvularia species have been more extensively studied since they are
known as cellulase producers17.

2. Case History

A young boy of 17 years of age came up at a tertiary care hospital situated at a rural
place in Nagpur, Maharashtra, India with a foreign body injury probably a stick to the right
eye with his cornea teared on the 2nd day after injury. Initially on the 1st day he noticed
redness, lacrimation and slight pain in the eye on arriving at home which was relieved on hot
fomentation for few minutes. On next day morning patient experienced severe lacrimation,
pain and redness in the affected eye with blurring of vision.

Fig.1 Corneal Ulcer With Fungal Overgrowth

3. Treatment

The patient was immediately rushed to the ophthalmic surgery and dead, necrosed
corneal tissue was removed with exophytic inflammatory fungal sequestration, treated by
superficial lamellar keratectomy, and corneal perforation, managed by penetrating

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keratoplasty. The patient was admitted in the ophthalmology ward with empirical
antimicrobial and antifungal coverage.

4. Laboratory Diagnosis

The corneal scrapping was sent in emergency for further diagnosis to the
microbiology department. The corneal tissue was inoculated on blood agar at 370C in an
incubator, chocolate agar at 370C in an incubator at capnophilic environment in a candle jar
and on a slope of Sabouraud’s Dextrose Agar (SDA) one at 370C in an incubator and another
at 250C at room environment. All the medias were inoculated and incubated with aseptic
precautions18. The Gram stained slide and the KOH mount of the corneal tissue was
examined. The Gram’s preparation showed 1-2 pus cells per High Power Field (HPF) with no
Gram positive or negative organisms, no buddying yeast cells, hyphae or pseudohyphae and
no fungal hyphae on KOH mount were seen. Preliminary reports of Gram’s stain and KOH
mount were given with the information that culture report to be followed for the further 3
weeks on every Monday18. The blood agar and chocolate agar plates were examined for any
growth after 24 hours and 48 hours of incubation. There was no growth on blood agar and
chocolate agar. Both inoculated slopes of SDA were examined for any growth everyday for
the 1st week and then twice a week for the next 2 weeks. There was no growth on a SDA
slant incubated at 250C at room environment even after 3 weeks and was discarded and thus
any possibility of growth of a dimorphic fungus was ruled out18.

The slant which was incubated at 370C in an incubator showed a growth after 6
days of incubation.

Macroscopic examination: The growth was woolly; greyish-black on obverse side and dark
on reverse.

Fig. 2 and 3 Growth characters of the Curvularia species on obverse and reverse side

Microscopic examination: On Lacto-Phenol Cotton Blue (LCB) mount, it showed the

growth of a monomorphic septate myecelium. Conidiophores were both simple and branched.
Macroconidia were large, dark, curved due to swelling of central cell. There were not more
than four cells in a branch. Few small chains of pigmented chlamydospores were also found.

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Fig.4 Microscopic morphology of Curvularia species on LCB mount

5. Discussion

Curvularia is the most common oculomycosis2,3,13,14,19 isolated in ocular traumas especially

when the trauma is due to wooden or plant materials. Depending upon microscopic
morphological characters, Curvularia species was differentiated from Alternaria20,21,22
species, Fusarium species20,21,22,23, , Bipolaris23 species and Exserohilum species23.
Curvularia geniculata and C. lunata are encountered to be the most common causative
organisms of oculomycosis among Curvularia species23. Apart from keratomycosis,
Curvularia is known to cause, sinusitis, onychomychosis, phaeohyphomycosis, eumycetoma,
etc10,11,12,13,14,15,23. However, if proper aseptic precautions are not taken while inoculating and
incubating the medias at appropriate temperatures this species is found to be the most
common laboratory media contaminant22,23. The routine laboratory diagnosis on the basis of
macroscopic and microscopic features are enough for patient’s medical treatment
management as soon as possible. Apart from this, immunodiagnosis23 on the basis of
molecular techniques and animal pathogenecity23 can also be used for the diagnosis of
oculomycosis. The only thing of being, a most common laboratory contaminant, the patience
required to maintain the aseptic measures and identify on the basis of microscopic
characteristics can help from not missing the diagnosis of Curvularia like oculomycosis.

References

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