What to know
- Presentation Day/Time: Friday, April 25, 2:55–4:00 pm
- Presenter: Michelle Chang, MD, EIS officer assigned to the National Center for State, Tribal, Local, and Territorial Public Health Infrastructure and Workforce
What did we do?
- On December 18, 2024, a clinical laboratory notified the New York City Health Department of multiple patients with Purpureocillium lilacinum keratitis after undergoing procedures at an ophthalmology clinic (Clinic A). We investigated to identify exposures associated with illness and recommend control measures.
What did we find?
- We identified three cases. All patients experienced vision loss; one required corneal transplantation.
- Infection prevention and control (IPC) assessment identified opportunities to improve instrument reprocessing, environmental cleaning, medication safety, and exposure to nonsterile water.
- Clinic A used consumer-grade cool-mist humidifiers in the procedure room, and we observed an undated bottle of sterile saline solution used for intra-operative irrigation for multiple patients across multiple weeks.
- We conveyed IPC recommendations addressing these and other potential exposures to Clinic A staff.
- Antifungal susceptibility testing results supported resistance to amphotericin B and susceptibility to azoles.
Why does it matter?
- Purpureocillium lilacinum caused severe disease in all three patients.
- Although we did not identify a definitive transmission route, our investigation uncovered and addressed multiple opportunities for exposure to environmental molds because of breakdowns in IPC practices.
Abstract Category: Fungal Diseases