Veterinary Ophthalmology (2012) 1–4 DOI:10.1111/j.1463-5224.2012.01012.

CASE REPORT

Scedosporium apiospermum keratomycosis in a dog

Emma J. W. Newton
Priory Veterinary Group, 59 Purewell, Christchurch, Dorset BH9 1HP, UK

Address communications to: Abstract

E. Newton
Tel.: +44-01202-484466
Fax: +44-01202-470141
e-mail: emmanewton@prioryvet
group.com
A 6-year-old male castrated Norfolk Terrier dog was examined following a 21-day
history of an increasingly painful eye. Examination revealed marked blepharospasm
and purulent ocular discharge associated with an ulcerative keratitis. There was
panstromal corneal opacity with raised gray to white lesions. Corneal cytology
demonstrated branching septate fungal hyphae identified by polymerase chain reaction
as Scedosporium apiospermum. Treatment with topical 1% voriconazole solution was
successful in resolving the keratomycosis.
Key Words: canine, cornea, eye, keratomycosis, Scedosporium, voriconazole

affected eye. There was a panstromal corneal opacity with

INTRODUCTION
Mycotic keratitis is considered to be rare in the dog; how-
ever, it is not uncommon in humans and horses.1 Fungal
organisms previously reported in cases of canine keratomy-
cosis include Aspergillus sp., Alternaria, Acremonium, Cepha-
losporium, Candida, Curvularia, Fusarium, Hormographiella,
Pseudallescheria, and Scedosporium spp.2–6 Culture, cytology,
and histology can aid in diagnosis, and now more recently,
polymerase chain reaction (PCR) has been used to provide a
precise diagnosis.1,2 New drugs, specifically voriconazole,
have been evaluated for the treatment of mycotic infections
in humans.7 It has subsequently been evaluated in horses,
and there are two case reports in which it has been used one
in a dog and the other in a cat.8–10 This case report details
the clinical presentation, diagnosis, and management of a
dog with Scedosporium apiospermum keratomycosis and treat-
ment with voriconazole.
CASE REPORT
A 6-year-old male castrated Norfolk Terrier was presented
for ulceration of his left eye. The owner had noted a sore eye
and started treatment with fusidic acid (Fucithalmic Vet;
Dechra, Uldum, Denmark) 21 days previously. The dog had
been on systemic steroids (prednisolone 0.5 mg/kg per os)
for inflammatory bowel disease for the previous 3 months.
There was marked blepharospasm of the left eye with
copious purulent discharge and photophobia. Dazzle and
palpebral reflex were positive, but the menace response was
negative. The pupillary light reflex (PLR) could not be
assessed. Severe conjunctival hyperemia was present in the
irregularly raised gray to white lesions and signs of kerato-
malacia. The cornea was 80% fluorescein positive. The left
eye could not be directly examined beyond the cornea.
Schirmer 1 tear test (STT) was 23 mm/min in the left eye
and 13 mm/min in the right eye. Intraocular pressure (IOP)
measured by applanation tonometry, (Tonopen XL;
Medtronic Solan, Jacksonville, FL, USA) was 13 mmHg in
the left eye and 18 mmHg in the right eye.
In the right eye, menace response, dazzle reflex, palpebral
reflex, PLR, and consensual PLR (left to right) were normal.
Ophthalmic examination with a slit-lamp biomicroscope
(Kowa SL-4; Kowa Company, Tokyo, Japan) and an indirect
ophthalmoscope (Keeler All Pupil; Keeler, Windsor, UK)
using a 20-diopter condensing lens (Volk Optical, Mentor,
OH, USA) was normal.
The dog was admitted, and a corneal scrape was taken
from the center of the ulcer using a Kimura spatula under
topical local anesthesia (0.5% proxymetacaine hydrochlo-
ride, Minims; Bausch & Lomb, Kingston-Upon-Thames,
UK). A corneal swab was also taken for bacteriological and
fungal culture.
Topical medication was commenced with serum every
hour, ofloxacin 0.3% eye drops (Exocin; Allergan, Marlow,
UK) every 2 h, and atropine 1% eye drops (Martindale,
Romford, UK) every 4 h until the time of surgery. Systemi-
cally buprenorphine 25 lg/kg (Vetergesic; Alstoe, Hull,
UK) and amoxicillin and clavulonic acid 8.75 mg/kg
(Augmentin; GlaxoSmithKline, Uxbridge, UK) were given
intravenously every 8 h. Systemic prednisolone was stopped.
Sixteen hours after admission, the left eye was more
comfortable, but the appearance had not changed markedly.

 2012 American College of Veterinary Ophthalmologists

2 newton
A tapetal reflex was apparent as the pupil was now dilated,
but no intraocular detail could be appreciated. The patient
was premedicated with acepromazine 30 lg/kg (Calmivet;
Vetoquinol, Caedex, France) and buprenorphine 20 lg/kg.
General anesthesia was induced with intravenous 1% propo-
fol 4 mg/kg (Vetofol; Norbrook, Carlisle, UK) and main-
tained with isofluorane (Isoflo; Abbott, Maidenhead, UK) in
oxygen (flow rate 6 L/min).
A superficial keratectomy was performed with the aid of
an operating microscope (Zeiss Opmi MD, Germany). The
cornea was very malacic, and approximately 1/3 depth of
corneal stroma was removed over 80% of the cornea surface.
Material from the keratectomy was not submitted for
analysis.
Cytology results, from the original scrape, were received
on the day the keratectomy was performed. The slides dem-
onstrated a high number of branching septate hyphae pre-
sumed to be fungal organisms (Fig. 1) and a moderate
number of neutrophils, a few small lymphocytes, and occa-
sional macrophages. No bacteria were seen.
Medication was started and revised as summarized in
Table 1.
There was no bacterial growth on blood agar (aerobic and
anaerobic conditions), MacConkey agar, and staph/strep
selective agar incubated at 37 C for 3 days. There was no
fungal growth on Sabaurad’s agar and dermatophyte selec-
tive agar at both 30 C and 37 C for 14 days. The cytology
slides, from the original corneal scrape, were then submitted
for PCR analysis (National Mycology Reference Labora-
tory, Health Protection Agency, Bristol, UK). DNA was
extracted from the corneal scrape by bead beating and puri-
fied using the QIAamp DNA blood mini kit according to the
manufacturer’s instructions (Qiagen, Crawley, UK). PCR
was performed on the DNA extract, and the resulting prod-
uct sequenced as described previously.11 Scedosporium apio-
spermum was identified.
Figure 1. Corneal cytology. Fungal hyphae and a few neutrophils are
visible. Modified Wright stain. ·100 objective.
 2012 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 1–4
Blepharospasm was still present 24 h post keratectomy.
There was no tapetal reflex because of generalized increase
in corneal opacity. The ulcerated area protruded anteriorly.
It was surrounded by a clearly defined stromal edge with
slight underruning of the peripheral epithelium. Dense mid-
to-deep stromal vascularization extended circumferentially
from the limbus approximately 2 mm toward the axial
cornea.
The dog was hospitalized for the following 6 days during
which time there was a gradual reduction in ocular pain
(reduced blepharospasm, photophobia, and lacrimation).
Chemosis reduced and dense vascularization progressed
from the limbus toward the central ulcer that began to
re-epithelialize.
Twenty-eight days after initial evaluation, the dog’s left
eye was very comfortable. There was a positive menace
response and dazzle reflex. The pharmacologically dilated
pupil could now be visualized. The cornea was clearing
peripherally, and axially, there was a small area of raised
granulation tissue with a fluorescein-positive area.
Thirty-five days after initial evaluation, the ulcer had
healed. Further reduction in corneal opacity was noted, leav-
ing only a very small central area of granulation tissue with a
teardrop shaped superficially pigmented lesion laterally. A
clear tapetal reflex could be obtained dorsally and a PLR. All
medications were stopped.
DISCUSSION
Fungi may be part of the normal ocular surface flora in all
species. A study in Florida isolated fungi from the conjuncti-
val sac of 95% of horses, 100% of cows, 22% of dogs, and
40% of cats in their sample population.12 In horses, com-
mensal fungi have become pathogenic after corneal injury,
in the presence of tear film instability and after treatment of
corneal ulceration with topical antimicrobials or corticoster-
oids (or both).13 In this case, there was no history of initiat-
ing trauma. There was, however, a 21-day period of
antibiotic use. There was also a long history of systemic cor-
ticosteroid use, which has been associated with keratomy-
coses in some domestic animals.14 In this case, corneal
cytology allowed a rapid, simple, and effective method of
obtaining a diagnosis of keratomycosis.
Combined medical and surgical therapy is indicated in
some cases of keratomycoses. Surgical methods indicated
for horses include conjunctival pedicle grafts, bridge grafts,
hood grafts, island grafts, and full-thickness penetrating ker-
atoplasty.13 A lamellar keratectomy and conjunctival pedicle
flap were performed in a dog with keratomycosis because of
Hormographiella aspergillata 1 week after unsatisfactory
improvement on medication alone.2 A conjunctival pedicle
graft was not performed at the time of keratectomy in this
case as the cornea was considered too edematous to hold
sutures.
The severity of the ulceration in this case necessitated the
use of medication to prevent collagenolysis. Whole fresh

Table 1. Medications given after a diagnosis of fungal keratitis
Topical medication (one drop left eye)
Whole blood
Ofloxacin (Exocin; Allergan, Marlow, UK)
Atropine (Martindale, Romford, UK)
Voriconazole* (Vfend; Pizer, Sandwich, UK)
Systemic medication (per os)
Tramadol (Tramadol; Relonchem, London, UK) (3 mg/kg)
Doxycycline (Ronaxon; Merial, Harlow, UK) (10 mg/kg)
Ranitidine (Zantac; GlaxoSmithKline, Uxbridge, UK) (2 mg/kg)
Sucralfate (Antepsin; Chugai Pharma; London, UK) (1 mg/kg)
Meloxicam (Metacam; Boehringer, Bracknell, UK) (0.1 mg/kg)
q = every
*1% concentration used. 200-mg vial reconstituted with 20 ml sterile water and kept refrigerated between 2 and 8 C.
serum taken from this dog was consistently very lipemic, so
whole blood was substituted instead as this was a simpler
approach. Topical antibiotics were also administered as rec-
ommended along with medication for the control of the sec-
ondary iridiocyclitis.1,15 A similar approach to medication is
reported in other case reports where additional support to
the damaged cornea and inflamed eye is considered neces-
sary.2,9,10 Systemic doxycycline was administered because of
its antiproteinase action, which has been proven in vitro and
detectable levels found in the preocular tear film of horses
following oral administration.16 Ranitidine and sucralfate
were administered to protect against gastrointestinal com-
plications that might have arisen from abrupt cessation of
prednisolone medication and immediate substitution of me-
loxicam.
Other fungal organisms previously reported in cases of
canine keratomycoses include most commonly Aspergillus
sp. as well as Alternaria, Acremonium, Cephalosporium, Can-
dida, Curvularia, Hormographiella, Pseudallescheria, and Sce-
dosporium spp.2–6 Scedosporium apiospermum is the asexual
form of Pseudallescheria boydii.17 It is a saprophytic fila-
mentous fungus that has been isolated from soil, sewage,
polluted water, and manure.17,18 In humans in the tropics,
it is a common cause of mycetoma, and systemic infec-
tions have been reported in immunocompromised
patients.17 The range of human disease also includes kera-
tomycosis with a high rate of corneal perforation, end-
ophthalmitis, posterior scleritis and orbital cellulitis,
meningitis, brain abscess and pulmonary infection and
death.19 Other diseases caused by S. apiospermum in the
dog include nasal granuloma and mycosis of the abdomi-
nal cavity.20,21
There is a previous report of S. apiospermum being cul-
tured from a dog with fungal keratitis in Sacramento, Cali-
fornia.3 The dog responded to topical and subconjunctival
injections of miconazole. A dog in Wisconsin, Madison, was
diagnosed with the asexual fungal form, but the globe was
enucleated because of a guarded prognosis at presentation.4
There is one previous report from Bern, Switzerland, of
PCR being used to aid the diagnosis of canine keratomyco-
sis.2 As in this case, both bacterial and fungal cultures were
 2012 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 1–4
S. APIOSPERMUM keratomycosis 3
Frequency of Duration of application/
application administration (days)
q1 h, q4 h at night 7
q4 h 35
q24 h 28
q2 h for 48 h then q4 h 35
q12 h 5
q24 h 10
q8 h 28
q8 h 28
q24 h 28
negative although cytology had demonstrated the presence
of branching fungal hyphae. Samples were submitted for
PCR after a negative culture result. In this case, one stained
cytology slide was sufficient to allow identification of the
fungi. Studies suggest that PCR is more sensitive than cul-
ture as a diagnostic aid in ophthalmic mycoses.22 Some PCR
assays only require six to eight hours to generate results,
which compares to fungal culture at 5–15 days.22 PCR per-
formed early on in the case presentation may allow specific
organism identification, and the published data of antifungal
sensitivity of various fungal organisms can then aid in choice
of antifungal agent.
Voriconazole was selected as the antifungal treatment in
this case. It is available in the UK as tablets, intravenous
injection, oral suspension, and as an ocular preparation.
Voriconazole 1% complexed with sulfobutyl ether b-cyclo-
dextrin (Vfend; Pizer, Sandwich, UK) is a human intrave-
nous triazole antifungal preparation. It is modified from
fluconazole to extend its spectrum of activity, so that it is
effective against yeast, filamentous fungi, and dimorphic
fungi.23 At high concentrations, it has proven to be fungi-
cidal rather than fungistatic.24 It also has a lower minimal
inhibitory concentration for many fungal organisms than
other azole drugs. Research has shown that it penetrates the
anterior and posterior segments of the eye in rabbits after
topical administration.25 Trials in horses with clinically nor-
mal eyes also treated with 1% topically administered vorico-
nazole solution had detectable levels measured in their
aqueous humor showing effective penetration of an intact
cornea.8 This suggests that previous recommendations that
an intact cornea should be debrided or a keratectomy per-
formed to enhance the penetration of antifungal drugs need
not apply with topical voriconazole.15 Topical 1% vorico-
nazole has been well tolerated in the cat,10 a dog,9 and as in
this case.
To the authors’ knowledge, this is the first case report of
fungal keratitis in the dog in the UK. A fungal infection was
first diagnosed on cytology and then PCR enabled successful
diagnosis of the fungal species. Following treatment with
topical 1% voriconazole for 5 weeks, the dog was noted to
be clinically free of keratomycosis.
4 newton
ACKNOWLEDGMENTS
I thank Prof. S. Crispin for her proof reading skills and sug-
gestions and Pfizer for their financial help with the cost of
PCR.
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