항진균제 다제 투여로 치료한 Pseudallescheria boydii 괴사성 공막염
Pseudallescheria boydii Necrotizing Scleritis Treated with Several Antifungal Agents
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목적: 익상편절제술 이후 발생한 Pseudallescheria boydii (P. boydii) 괴사성 공막염에서 항진균제 다제 투여로 성공적으로 치료한경험을 보고하고자 한다. 증례요약: 6년 전 익상편절제술 과거력이 있는 73세 여자 환자가 2주간 고용량 스테로이드 치료하 점차 악화되는 좌안 공막염으로의뢰되었다. 초진 시 좌안 윤부에 인접한 이측부 공막에 타원형의 공막궤양이 관찰되었다. 이에 스테로이드 일체 중단하 1% 보리코나졸, 5% 나타마이신, 2.5% 반코마이신, 5% 세프타지딤 안약 매시간 점안 및 경구 보리코나졸 200 mg/일 복용을 시작하였으나 지속악화되었다. 치료 10일째 사상 진균인 P. boydii가 동정되었으며, 0.5% 카스포펀진 안약을 추가 점안하고 보리코나졸은 2%로 농도로변경하여 점안하였다. 이후 치료 6주째 병변부 상피화에도 불구하고 맥락막박리가 발생하여 항진균 치료를 지속하면서 전방 내 점탄물질을 주입하였고, 치료 14주째 공막괴사 부위가 완전히 상피화되고 맥락막박리는 소실되었다. 결론: 익상편절제 후 발생한 P. boydii 앞공막염의 성공적인 치료를 위해 장기간 적극적인 항진균제 다제 치료를 고려해볼 수 있겠다.
Abstract
Purpose: We report a case of post-pterygium excisional Pseudallescheria boydii (P. boydii) necrotizing scleritis successfully treated with multi-antifungal agents. Case summary: A 73-year-old female with a history of pterygium excision 6 years prior was referred to our institute because of worsening scleritis in the left eye during high-dose, 2-week steroid treatment. On the initial visit, an oval ulcer was observed in the temporal sclera adjacent to the limbus. All steroids were stopped and 1% voriconazole, 5% natamycin, 2.5% vancomycin, and 5% ceftazidime eyedrops were applied every hour and oral voriconazole 200 mg prescribed once a day, but the scleral necrosis continued to worsen. On day 10, the filamentous fungus P. boydii was isolated; 0.5% caspofungin eyedrops were added and the topical voriconazole concentration increased to 2%. Six weeks later, despite epithelization over the scleral necrosis, choroidal detachment developed. The antifungal treatment was continued and a dispersive, ophthalmic viscosurgical device inserted in the anterior chamber. At 14 weeks of treatment, the scleral necrosis was completely epithelialized and the choroidal detachment had disappeared. Conclusions: When encountering a case of P. boydii-caused necrotizing scleritis developing after pterygium excision surgery, long-term intensive treatment with several antifungal agents must be considered.
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