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Severe Inflammatory Response in a Patient on Oral Miltefosine for Acanthamoeba Keratitis

A 29 year-old South Asian male presented with 4 months of fluctuating pain, photophobia, and decreased vision in his left eye. He had been treated with topical steroids intermittently and oral acyclovir without improvement. His visual acuity was 20/20 OD and counting fingers (CF) OS. Slit lamp examination of the left eye revealed conjunctival injection and a ring infiltrate in the cornea. He had no history of contact lens wear or fresh water exposure, but the history and the presence of a ring infiltrate were suspicious for Acanthamoeba keratitis (AK). Topical steroids and oral acyclovir were discontinued (once PCR for HSV was negative) and he was started on polyhex-amethylene biguanide (PHMB) 0.02% Q1H, propamidine 0.1% QID and moxifloxacin 0.5% QID. Although confocal micro-scopy had been unrevealing, polymerase chain reaction (PCR) testing from the initial presentation confirmed the diagnosis of AK.