Predicting Prognosis Based on Regional Prevalence, Ulcer Morphology and Treatment Strategy in Vision-Threatening Pythium insidiosum Keratitis

Pythium insidiosum is an oomycete belonging to the phylum Straminipila and family Pythiaceae. It causes rapidly progressive vision-threatening keratitis. Clinically, microbiologically and morphologically, it closely resembles fungal keratitis; hence it is also labelled as a “parafungus”. The clinical features mimicking fungus are subepithelial and stromal infiltrate, endo-exudates, corneal melt and hypopyon. The hallmark features of Pythium are tentacular projections, reticular dot-like infiltrate, peripheral furrowing and thinning, and rapid limbal spread. Microbiological corneal smearing on KOH and Gram stain reveal septate or aseptate, obtuse to perpendicular hyphae which mimic fungal hyphae. Culture on any nutritional agar reveals cream, cottonwool-like, fluffy colonies, and diagnosis is confirmed by zoospore formation by the leaf incarnation method. Medical management with antifungals and antibacterials still presents a dilemma. Early therapeutic keratoplasty has been the proposed treatment in most cases. We hypothesize that the prognosis of Pythium keratitis is governed by regional geographical variations, ulcer size and density on presentation, and initial treatment strategy. The available literature supporting the proposed hypothesis is also discussed, along with the hallmark features of Pythium and how it masquerades as other microorganisms causing keratitis. We also aim to propose a novel diagnostic and treatment algorithm for managing this vision-threatening keratitis.