a case report of a 56-year - old male farmer who sought medical attention after a month - long evolution of irritative symptoms in his right eye , accompanied by visual acuity ( va ) impairment .
the patient received topical and oral broad - spectrum antibiotic treatment with no improvement before being referred to a cornea specialist , where he was found to have va of 20/150 and was noted on biomicroscopy to have endothelial feathery coalescent lesions .
the patient was admitted to the hospital for an aqueous humor sample and intravenous voriconazole .
however , clinical evidence of improvement was confirmed after 5 days of antimycotic intravenous therapy .
complete clinical resolution was achieved at 1 month after treatment completion with oral voriconazole , as evidenced by va of 20/20 and disappearance of endothelial lesions .
endothelial involvement by fungi is a rare condition . in this case , no microbes were isolated , but the characteristic morphology of the lesions , the history of onychomycosis , and the spectacular response to voriconazole turn this case into a valid presumptive diagnosis .
the cornea is the ocular structure most commonly affected by fungi . most often , the source of infection is exogenous , such as vegetal trauma , among others .
in addition , it is associated with any disease affecting the eye s normal surface , such as persistent epithelial defects , neurotrophic ulcers , use of contact lenses , and secondary attenuation of cell defense mechanisms after topical steroids.15 infectious endothelial involvement of the cornea has been mainly attributed to different viral species.6 however , herein we present the case of a patient with a clear endothelial infectious involvement that successfully responded to systemic antifungal therapy with voriconazole .
a 56-year - old male banana grower sought medical attention after a month - long evolution of irritative symptoms in his right eye accompanied by visual acuity ( va ) impairment .
his medical history confirmed excision of bilateral pterygium 15 years earlier , but no recent ocular trauma was related by the patient .
the general medical practitioner ( nonophthalologist ) initiated treatment with topical prednisolone acetate 1% and gentamicin sulfate 0.3% every 6 hours for 1 week for a presumed bacterial conjunctivitis , but the patient was referred to the ophthalmologist after lack of success with this therapy .
an initial diagnosis of infectious keratitis ( with unaffected epithelium but endothelial involvement ) was made , and treatment with topical moxifloxacin chlorhydrate 0.5% four times per day and gentamicin sulfate 0.3% three times per day plus oral ciprofoxacin 750 mg every 12 hours was prescribed .
after 6 days on this therapeutic regimen and with lack of clinical improvement , the patient was referred to a cornea specialist .
he was found with right eye va of 20/150 and normal va in his left eye .
the biomicroscopy performed on the affected eye confirmed the integrity of the epithelium with an unruptured bulla over the pupillary area , presence of folds on descemet s membrane , anterior chamber cells 2+(standardization of uveitis nomenclature working group),7 and multiple coalescent circular lesions of feathery and whitish appearance on the endothelium ( figure 1a ) .
fundoscopic examination with an indirect ophthalmoscope under midriasis was normal . based on these findings ,
therefore , the patient was admitted to hospital to further explore the etiology of the lesion .
for this , an aqueous humor sample was examined for fungi detection by culture and polymerase chain reaction ( pcr ) , and systemic antimycotic therapy was initiated immediately after sample taking . by recommendation of the infectologist ,
the patient was empirically treated with voriconazole 200 mg intravenously ( iv ) every 12 hours ( diluted in 250 ml of 0.9% saline solution administrated over 2 hours ) and topical gatifloxacin 0.3% every 6 hours for 1 week ( as post puncture antibacterial prophylaxis ) .
after 3 days on iv therapy with voriconazole , the patient showed significant clinical improvement , evidenced by an important decline in the number of cells within the anterior chamber and some reduction on the feathery endothelial lesions described previously .
aqueous humor microbiologic study was negative ( gram , potassium hydroxide staining , aerobic , anaerobic , and fungal cultures ) .
pcr , venereal disease research laboratory , herpes simplex , and hiv testing were also negative .
after 5 days on this regimen , the patient was discharged with voriconazole 200 mg orally every 12 hours . after a week , the patient was found to have va of 20/30 , considerable improvement of endothelial lesions , and faint residual corneal edema .
the same treatment regimen was administered for a further week , and fluorometholone 0.1% every 12 hours was added to therapy for edema .
examination 2 weeks after discharge confirmed further edema reduction and almost complete resolution of endothelial lesions .
after 4 weeks of antifungal treatment ( 3 weeks of those were as an outpatient ) , the patient showed full edema resolution , the presence of a few small endothelial scars , and 20/20 va ( figure 1c ) .
fluorometholone was then withheld and oral voriconazole was continued until completion of 2 months with antifungal therapy .
infectious endothelial involvement of the cornea has been mainly attributed to different viral species.6 however , we report an interesting case of a patient whose endothelial lesions suggest mycotic etiology that successfully responded to systemic antifungal therapy with voriconazole .
usual manifestations of fungal keratitis include epithelial and stromal ulceration , abscessing with stromal necrosis , epithelial or stromal edema and , rarely , cell reaction in the anterior chamber , hypopyon , and fibrin deposits within the anterior chamber and endothelial plates.1,5 nevertheless , the most striking finding in this case was the confinement of damage to endothelial plates with subsequent central corneal edema , bulla formation , folds on descemet s membrane , and cell reaction in the anterior chamber .
therefore , we propose an endogenous source of infection , and postulate the presence of recurrent onychomycosis as a risk factor in the absence of prior trauma or epithelial disruption . however , microbiological isolates turned out to be negative both in blood and in aqueous humor .
a characteristic clinical sign of fungal keratitis is the irregular nature of infiltrates , traditionally described as  feathery  or
 cotton wool.1,4,8 this feature prompted the suspicion of fungal origin in our patient , as this pattern was observed on the endothelium .
although gram and potassium hydroxide staining , as well as pcr , were negative , our diagnosis was established on clinical grounds and confirmed by the success of empirical therapy with voriconazole .
it is important to point out that laboratory diagnosis in this case has been limited by the low volume of sample taken , which was destined for multiple studies ( stains , cultures , pcr ) .
in addition , experience with these tests and available primers in our country are also limited .
some authors have reported on the good efficacy of intracameral injection with amphotericin b and voriconazole in cases of endophthalmitis secondary to keratitis.911 although this is an adequate therapeutic alternative , it was not required , as the patient showed an excellent response to systemic therapy with oral voriconazole .
an interesting case of a presumed endogenous mycotic endotheliitis is herein reported in a patient with a history of recurrent onychomycosis who develops endothelial lesions of mycotic morphology .
the patient responds to a systemic iv and oral scheme with voriconazole , and thus an endogenous and mycotic etiology is presumed .
however , this could not be confirmed by microbiological studies , due to the limitations that we have cited .
 purposeto report an interesting case of infectious endotheliitis of presumed mycotic origin.methodsa case report of a 56-year - old male farmer who sought medical attention after a month - long evolution of irritative symptoms in his right eye , accompanied by visual acuity ( va ) impairment . 
 the patient received topical and oral broad - spectrum antibiotic treatment with no improvement before being referred to a cornea specialist , where he was found to have va of 20/150 and was noted on biomicroscopy to have endothelial feathery coalescent lesions . 
 the patient was admitted to the hospital for an aqueous humor sample and intravenous voriconazole.resultsthe microbiological studies did not isolate any micro - organisms . 
 however , clinical evidence of improvement was confirmed after 5 days of antimycotic intravenous therapy . 
 complete clinical resolution was achieved at 1 month after treatment completion with oral voriconazole , as evidenced by va of 20/20 and disappearance of endothelial lesions.conclusionendothelial involvement by fungi is a rare condition . in this case , no microbes were isolated , but the characteristic morphology of the lesions , the history of onychomycosis , and the spectacular response to voriconazole turn this case into a valid presumptive diagnosis . 
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