Bipolaris (dematiaceous) Fungal Keratitis Masquerading as Herpetic Keratouveitis with Hypopyon and Secondary Ocular Hypertension.
Fatimah N Alzaher, Abdulaziz I Alsomali, Majed F Alsubaie et al.
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Case in brief
A 40-year-old farmer developed left-eye pain and marked visual loss after rubbing his eye following contact with vegetative material. Examination showed a dense central corneal infiltrate with an epithelial defect, endothelial plaque, keratic precipitates, and hypopyon. Initial microbiology was negative, and the presentation was treated as herpetic keratouveitis; worsening hypopyon and raised intraocular pressure prompted repeat sampling, anterior chamber wash, and corneal biopsy, which identified Bipolaris spp. Intensive topical and systemic antifungals, with intracameral and intrastromal injections, controlled the infection. A central scar required optical penetrating keratoplasty; the graft remained clear without recurrence at 14 months.
What made this case unusual
Bipolaris keratitis presented with features resembling herpetic keratouveitis, including hypopyon and secondary ocular hypertension, while initial microbiologic testing was negative.
Diagnostic / clinical pearl
When presumed herpetic keratouveitis worsens or responds poorly to empiric therapy, reconsider fungal keratitis; repeat sampling and deeper tissue diagnostics may identify an organism missed initially.