Fungal keratitis caused by a Pleosporales species following ocular trauma with a wooden fragment: a case report

Background Fungal keratitis is a vision-threatening infection, and cases caused by dematiaceous fungi belonging to the order Pleosporales are extremely rare. These infections present significant diagnostic and therapeutic challenges due to slow fungal growth, difficulty in morphological identification, and variable antifungal susceptibility. Case presentation We report the case of a 44-year-old male forestry worker who sustained an ocular injury from a wooden fragment and subsequently developed pain in the right eye. At presentation to our hospital (Day 0), direct microscopy (10% KOH wet mount and Fungiflora Y fluorescent staining), corneal culture, and a comprehensive ophthalmic infection multiplex real-time PCR panel (12-strip assay; 24 targets) were all negative, resulting in delayed pathogen identification. On Day 58, repeat corneal scraping culture yielded a filamentous fungus. Sequencing of the internal transcribed spacer (ITS) region classified the isolate within the order Pleosporales, however, definitive species-level identification was not achieved. Treatment was complicated by severe azole-induced hepatotoxicity on Day 39 (AST 540 U/L, ALT 1041 U/L), which required discontinuation of azole therapy and a switch to a multi-agent regimen. After liver function had improved, topical amphotericin B and systemic micafungin were initiated, followed by topical micafungin and oral terbinafine. Autologous serum eye drops (20%) were also initiated Day 191. The corneal lesion gradually stabilized, and at the final follow-up on Day 268, best-corrected visual acuity was 1.2, with a quiet anterior segment inflammation and a stable corneal scar. Conclusions This case highlights the importance of repeated microbiological sampling and molecular identification in suspected traumatic fungal keratitis, especially when initial diagnostic tests are negative and rare organisms such as Pleosporales species are suspected. It also emphasizes the need for flexible, stepwise therapeutic strategies when conventional azole-based regimens are contraindicated or ineffective.