진균각막염의 임상양상 및 예후

Clinical Manifestations and Prognostic Factors of Fungal Keratitis: Analysis in Patients Over a 20-year Period

목적: 최근 20년간 국내에서 발생된 진균각막염 환자의 임상양상, 원인균, 치료, 예후 등의 변화에 대해 알아보고자 하였다. 대상과 방법: 본원에서 각막염으로 진단받고 시행한 각막찰과 및 배양검사에서 진균이 검출된 177안의 의무기록을 후향적으로 조사하였다. 성별, 연령, 선행 요인, 원인균, 임상양상, 치료 방법, 예후 등을 분석하였다. 또한 배양과 KOH염색 여부에 따라 KOH양성그룹, 배양양성그룹, KOH-배양동시양성그룹으로 나누어 조사하였다. 불량한 임상결과와 관련 있는 위험인자를 로지스틱 회귀분석으로 조사하였다. 결과: 대상 환자의 평균연령은 67.4 ± 11.3세였고, 남자가 107명(60.5%)이었다. 진균각막염 발생의 위험인자는 안외상(57.6%), 특히 식물에 의한 외상(29.4%)이 많았다. 가장 흔한 사상진균은 푸사륨 49균주(31.6%)였고 효모균은 칸디다 17균주(11.0%)였다. 진균과 세균이 함께 배양된 41안 중 사상진균과 그람양성균이 29안(70.7%)으로 많았다. 치료 후 시력이 호전된 경우는 KOH양성그룹이 19명(79.2%), 악화된 경우는 배양양성그룹이 36명(40.4%)으로 흔하였다. 다변량분석에서 불량한 임상결과의 위험인자는 이전의 안질환(odds ratio [OR]: 3.744, p=0.010), 전방축농(OR: 2.941, p=0.030), 수술적 치료를 받은 경우(OR: 24.482, p<0.001)였다. 결론: 진균각막염은 KOH만 양성이면 임상양상이 양호하였고, 배양에서 균이 확인되면 심하였다. 진균이 의심되면 초기에 KOH염색과배양검사를 해야 하고, 불량한 임상결과의 위험인자가 있을 경우 조기에 최대한 약물치료를 시행해야 한다.

Purpose: To describe the clinical manifestations, causative organisms, treatment, and prognostic factors of fungal keratitis based on analysis of patients over the past 20 years. Methods: A total of 177 patients (177 eyes) with fungal keratitis, who were diagnosed by smears and cultures, were reviewed retrospectively. Sex, age, predisposing factors, causative organisms, clinical manifestations, treatment, and prognosis were evaluated. The patients were divided into three groups: only potassium hydroxide (KOH)-positive, only culture-positive, and KOH- and culture-positive. Logistic regression was performed to identify the factors associated with a poor clinical outcome. Results: The mean age of the patients was 67.4 ± 11.3 years; 107 (60.5%) patients were men. The most common predisposing factor was ocular trauma (57.6%), especially by plants (29.4%). The most prevalent filamentous fungi were Fusarium species (31.6%, 49 isolates), and the most prevalent yeasts were Candida species (11.0%, 17 isolates). In cases of bacterial and fungal keratitis, filamentous fungus with Gram-positive bacterial infection (70.7%, 29/41) was the most common presentation. Visual improvement after treatment was common in the KOH-positive group (79.2%, 19/24), while visual deterioration after treatment was common in the culture-positive group (40.4%, 36/89). Previous ocular disease (odds ratio [OR]: 3.744, p = 0.010), hypopyon (OR: 2.941, p = 0.030), and surgical treatment (OR: 24.482, p < 0.001) were risk factors for a poor clinical outcome in the multivariate logistic regression model. Conclusions: Clinical prognosis was good in the KOH-positive only group, but poor in the culture-positive group. If fungal keratitis is suspected, diagnostic KOH staining and culture tests should be performed initially. Early intensive antifungal medical treatments are necessary for patients with risk factors for poor clinical outcomes.