322 Letters Vol. 16, 1997 A Case of Alternaria Keratitis Treated with Fluconazole Keratitis caused by dematiaceous fungi is uncom- mon, mycotic keratitis often being traceable to a history of trauma to the eye with organic matter (1, 2). Alternaria is one of the genera of septate de- matiaceous fungi commonly occurring as soil saprophytes and plant pathogens. Alternaria spe- cies have occasionally been reported as human pathogens (1-9), but are an uncommon cause of keratitis (7, 8). We report a case of keratitis caused by an Alternaria sp. in a patient who un- derwent a cataract operation and who was success- fully treated with fluconazole. The 82-year-old man was admitted to our hospi- tal in July 1995 with pain and redness of the aphakic left eye of one-week duration.The patient had undergone surgery for extracapsular lens ex- traction due to cataracts of the left and right eye respectively 40 days and 10 years previously. The patient's complete blood count, fasting blood sugar level, and routine clinical chemistry test results were all within normal range. Visual acuity of the left eye was 20/400. Microscopic ex- amination of the left eye revealed moderate con- junctival hyperemia, mild chemosis, and a large, dense, whitish, elevated corneal ulcer (3 x 2 • 2 mm) occupying the inferior paracentral area of the cornea; and associated with marked corneal oede- ma and localized necrosis at its periphery. Corneal scrapings were obtained and submitted for bacterial and fungal investigation. On the fourth day of incubation, the cultures started to show growth of fungus but not bacteria. An Alter- naria species was identified in the culture on the basis of the characteristic microscopic morpholo- gy. In the initial stages of the culture on Sabouraud glucose agar, the colonies were cotton wool-like in appearance, and grey to black in colour. Micro- scopically, Alternaria had septate hyphae, charac- teristic septate conidiophores of variable length, and large club-shaped conidia with both transverse and longitudinal septations found singly or in chains. Upon receipt of the results of direct microscopic examination of the corneal scrapings on the day of admission, topical therapy with a fluconazole (1 mg/ml) suspension was begun which was admin- istered every hour for ten days. Treatment also in- cluded topical neomycin sulfate, gentamycin 0.3%, atropine 1%, phenylephrine 2.5%, and ar- tificial tear fluid drops. By the tenth day of treat- ment, the patient showed clinical improvement. The dose of fluconazole was then decreased to six times daily for 20 days. Clear signs of improvement were seen about one month later, and no fungi were grown from specimens of the corneal lesion at that time.There was no relapse during a further follow-up period of one month. At the end of this time, the patient's visual acuity was 20/100 and the corneal perforation had resolved completely but vitreous strands were still attached to the poste- rior corneal surface. Alternaria species have been documented as the cause of disease in both healthy and immunocom- promised hosts (1, 2, 9). True infection can be di- vided into two main categories: infections with a single focus often associated with prosthetic de- vices, and multifocal infections presumed to be due to inhalation and dissemination of the organism. The latter most often occur in immunocompro- mised hosts such as patients receiving corticoster- old therapy. Our patient had received therapy with topical corticosteroids during the postoperative period, and in his case these drugs may have been a predisposing factor for fungal keratitis (1, 2). Sev- eral cases of ocular Alternaria infections have been reported, including chronic endophthalmitis following intraocular lens implantation, infiltration of soft contact lens matrix, and keratomycosis fol- lowing corneal transplantation (5-8). Several different antifungal agents have been used for therapy of this infection, however no clear standard therapeutic approach has been estab- lished. Treatment of underlying disease is funda- mental, and spontaneous recovery of Alternaria in- fection followed by relapse has been described in such cases (2, 3). In the management of alternari- osis, therapy with topical or systemic antifungal drugs including miconazole, amphotericin B and flucytosine has been reported to be effective in some cases (1, 2), but not in others (9). The value of newer agents such as ketoconazole, fluconazole, and itraconazole is not clear, although a clinical re- sponse of Alternaria infections to therapy with these agents has been reported anecdotally (3, 4, 8, 9). In our case, the patient was treated with top- ical fluconazole with complete resolution of the infection. Unusual fungal organisms such as Alternaria spe- cies are now being identified as pathogens in in- vasive and local fungal infections, and cannot be automatically dismissed as laboratory contami- nants or colonizing flora. Precise identification of the isolates and evaluation of their possible clini- cal relevance is necessary if we are to improve our