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Adverse Occurrence type:
Only one of two tissue allografts derived from the same donated cornea caused a Candida albicans infection in recipients. The corneal rim used in the DSAEK in this case report became infected with Candida albicans.The anterior cap of the same donor cornea was used to perform a tectonic superficial anterior lamellar keratoplasty on another patient, and the recipient did not have any problem with fungal infection. The report did not disclose the outcome of any transplantation, if any, of the opposite donor cornea. The authors report that this patient in this case report was the only patient in their practice who developed infectious keratitis (regardless of cause from bacteria or fungi) after more than 300 consecutive DSAEK procedures.
Time to detection:
On the 10th postoperative day, a small whitish infiltrate was noted within the interface. The donor corneoscleral rim had been cultured for bacteria at the time of surgery. On discovering the infiltrate on post-op day 10, the lab was requested to add fungal cultures to the pre-operative culture. C. albicans contamination was reported 48 hours later.
Alerting signals, symptoms, evidence of occurrence:
After DSAEK surgery the patient was given tobramycin/dexamethasone drops daily and on day three was doing well. The patient returned for a routine followup on post-op day 10 and a small whitish infiltrate was noted within the interface. The donor corneoscleral rim had been cultured for bacteria at the time of surgery. On discovering the infiltrate on post-op day 10, the lab was requested to add fungal cultures. C. albicans contamination was reported 48 hours later. Vision was unimpaired, the patient had no symptoms, and eye was "quiet". Oral and topical voriconazole was prescribed. Twenty-one days after surgery, the infection worsened. It was present outside the interface and inside the anterior chamber, so a penetrating keratoplasty was performed in order to eliminate the infection. Intrastromal, intracamerular, and intravitreal 0.1% voriconazole was injected. The recipient cornea was sent to pathology and the examination revealed spores and hyphae by using periodic acid–Schiff (PAS) staining and Grocott technique. Eventually the infection was cured but other complications occurred and many procedures were needed resulting in only being able to detect hand movements.
Demonstration of imputability or root cause:
The donor-to-recipient transmission of C. albicans is probable but not proven. C. albicans was documented on the corneoscleral rim allograft from culturing it at the time of implantation.The post-op rim infection discovered on day 10 was assumed to be a fungal infection and anti-fungal drugs were given. The infiltrate and infection worsened and on day 21 the rim allograft and patient's cornea were removed and on lab exam fungal spores and hyphae were observed. C albicans was a contaminant on the donor tissue found at the time of surgery and a severe infection with fungal spores and hyphae was found on explanting the infected allograft tissue but without culturing it. Therefore there was no C. albicans isolated directly from the explanted infected tissue and no nucleotide sequencing could be performed to show identity between the C albicans on the allograft and on whatever fungus was on the explanted tissue. Only one of two tissue allografts derived from the same donated cornea caused a Candida albicans infection in recipients. In addition authors did not report the outcome of transplanting the tissue from the other eye of the donor, if any. They did not report any culture results, if any, performed by the eye bank that recovered and stored the eye bank.
Suggest new keywords:
cornea, DSAEK, Descemet stripping with automated endothelial keratoplasty, endophthalmitis. Candida albicans, donor infection, recipient infection. corneoscleral rim. fungal infection. disease transmission. keratitis.endophthalm
Candida keratitis after Descemet stripping with automated endothelial keratoplasty. Villarrubia A et al. Eur J Ophthalmol. 24(6):964-7, 2014 Nov-Dec.
see cases for C. albicans and cornea (ID 9 and 382) (EP)