Bilateral nummular infiltrates: An uncommon presentation of Candida keratitis

We present a case of misdiagnosed fungal keratitis due to a bilateral nummular presentation.

A 41-year-old female patient, contact lens wearer, presented initially at an optometrist with acute bilateral blurred vision and photophobia. She was found on exam to have multiple round stromal infiltrates bilaterally. She did not have significant ocular surface issues prior and had no history of topical steroid use. Adenovirus testing was negative, and she was started on a topical antibiotic-steroid combination. She did not improve and was referred for further evaluation. We initially suspected a herpetic infection and began treatment with oral antivirals. Cultures came back positive for Candida albicans in the right eye. She was very photophobic and cultures were unable to adequately be obtained from the left eye. She was switched to topical voriconazole drop in both eyes and gradually improved with excellent visual outcome. Urogenital cultures were negative. Contact lens use was discontinued through the course of treatment.

Bilateral Candida keratitis is rare and has not been reported in a nummular pattern and in a patient without significant ocular surface issues or chronic use of steroid drops. Differential diagnosis of nummular keratitis mostly includes viral and inflammatory conditions. This case highlights the need to stay alert to a possible fungal etiology and a potential risk of using topical steroids at initial presentation of nummular keratitis.