A 58-year-old woman with a history of hepatitis C, liver cirrhosis, hepatocellular carcinoma, hypothyroidism, and peripheral neuropathy presented to our clinic with left ear pain and blisters on her lips, nose, and mouth. On exam, the patient’s left tympanic membrane was opaque, and she had multiple 3- to 5-mm irregularly shaped ulcers on her right buccal mucosa, gingiva, and lips. She was given a diagnosis of acute otitis media and prescribed a course of amoxicillin. The physician, who was uncertain about the cause of her gingivostomatitis, took a “shotgun approach” and prescribed a nystatin/diphenhydramine/lidocaine mouthwash.
Three weeks later, the patient returned complaining of cloudy urine, dysuria, fever, vomiting, and “pink eye.” On exam, her right eye was mildly injected with no drainage. She had normal eye movements and no ophthalmoplegia. We diagnosed viral (vs allergic) conjunctivitis and pyelonephritis in this patient and advised her to use lubricant eyedrops and an oral antihistamine for the eye. We also started her on cefpodoxime (200 mg bid for 10 days) for pyelonephritis.
Three days later, the patient called our clinic and said that her right eye was not improving. We prescribed ofloxacin ophthalmic drops, 1 to 2 drops every 6 hours, for presumed bacterial conjunctivitis.
Four days later, she returned to our clinic; she had been using the ofloxacin drops and antihistamine but was experiencing worsening symptoms, including itching of her right eye, associated blurriness, and decreased vision. She had been using a warm compress on the eye and found that it was getting sticky and crusted. A gray corneal opacity was seen on physical exam, and a fluorescein exam was performed (FIGURE).
