Candida dubliniensis endophthalmitis: first case in North America

To report an unusual case of endogenous fungal endophthalmitis due to Candida dubliniensis. Interventional case report of a 27-year-old immunocompetent male with loss of vision, dense vitritis, and chorioretinal infiltrates, who underwent a diagnostic pars plana vitrectomy. Microbiology cultures obtained by a diagnostic vitrectomy were positive for the growth of C. dubliniensis. This infectious process was then appropriately treated with intravitreal amphotericin B and systemic fluconazole with resolution of the endophthalmitis. Endogenous fungal endophthalmitis is a condition that can masquerade other more common causes of endophthalmitis. Atypical cases of endophthalmitis may benefit from diagnostic pars plana vitrectomy for prompt diagnosis and treatment.     

Endogenous fungal endophthalmitis following intensive corticosteroid therapy in severe COVID-19 disease

Purpose:To report endogenous fungal endophthalmitis, postrecovery from severe COVID-19 infection in otherwise immunocompetent individuals, treated with prolonged systemic steroids.Methods:Retrospective chart review of cases with confirmed and presumed fungal endogenous endophthalmitis, following severe COVID-19 disease, treated at two tertiary care referral eye institutes in North India.Results:Seven eyes of five cases of endogenous fungal endophthalmitis were studied. All cases had been hospitalized for severe COVID-19 pneumonia and had received systemic steroid therapy for an average duration of 42 ± 25.1 days (range 18–80 days). All the cases initially complained of floaters with blurred vision after an average of 6 days (range 1–14 days) following discharge from hospital. They had all been misdiagnosed as noninfectious uveitis by their primary ophthalmologists. All eyes underwent pars plana vitrectomy (PPV) with intravitreal antifungal therapy. Five of the seven eyes grew fungus as the causative organism (Candida sp. in four eyes, Aspergillus sp. in one eye). Postoperatively, all eyes showed control of the infection with a marked reduction in vitreous exudates and improvement in vision.Conclusion:Floaters and blurred vision developed in patients after they recovered from severe COVID-19 infection. They had received prolonged corticosteroid treatment for COVID-19 as well as for suspected noninfectious uveitis. We diagnosed and treated them for endogenous fungal endophthalmitis. All eyes showed anatomical and functional improvement after PPV with antifungal therapy. It is important for ophthalmologists and physicians to be aware of this as prompt treatment could control the infection and salvage vision.     

Bilateral <Emphasis Type="Italic">Candida albicans</Emphasis> Endophthalmitis Associated with an Infected Deep Venous Thrombus

Background To describe the clinical and histopathologic findings in a patient with bilateral Candida albicans endophthalmitis due to an infected deep venous thrombus.Case A 43-year-old patient with bilateral Candida albicans endophthalmitis due to an infected central venous thrombus. The patients ophthalmology and hospital charts were reviewed. Histopathologic sections of the Candida albicans retinal granuloma were examined under light microscopy.Observations Our patient had multiple blood cultures positive for Candida albicans owing to an infected subclavicular venous thrombosis. Bilateral Candida albicans endophthalmitis was diagnosed. Bilateral vitrectomy and membrane peeling for macular traction retinal detachments were performed. In the right eye, a large retinal granuloma was excised during surgery to adequately relieve traction on the macula. Vision improved in both eyes after surgery. Histopathologic findings revealed branching hyphae surrounded by giant cells, endothelial cell-lined vascular channels, and inflammatory cells.Conclusions This is the first report of an infected deep venous thrombosis causing bilateral endogenous endophthalmitis. Appropriate management of these patients requires clear differentiation between endogenous chorioretinitis and endophthalmitis. Patients with documented fungemia should have a dilated fundus examination on a regular basis until complete clearance of the infection. Jpn J Ophthalmol 2004;48:30–33 © Japanese Ophthalmological Society 2004     

A Case of Candida albicans Endophthalmitis with No Predisposing Risk Factors and a Distant Source of Infection

Purpose

To report a case of Candida albicans endophthalmitis with no identifiable predisposing risk factors.

Case Report

A 57-year-old male presented with a 3-day history of worsening floaters and reduced visual acuity. Fundoscopy and optical coherence tomography showed presence of fluffy white preretinal and intraretinal infiltrates. With no past medical history or evidence of immunosuppression but having travelled abroad and suffered from diarrhoea, fungal aetiology was thought to be unlikely and as a result, treatment was commenced for toxoplasma. Despite treatment, his vision did not improve. Initial investigations including inflammatory markers, serology for toxoplasmosis, blood culture, chest radiograph and aqueous sampling could not identify a source of infection. However, polymerase chain reaction results from vitreous sampling revealed C. albicans. As a result, the patient was treated with intravenous voriconazole and intravitreal amphotericin B. As initial clinical improvement was limited, a vitrectomy was performed with further intravitreal amphotericin B. Clinical improvement was rapid following vitrectomy. After repeated Gram staining and culture of infected toenails, Gram-positive yeast cells were isolated.

Conclusion

Although C. albicans is a frequent cause of endogenous endophthalmitis, patients often have one or more predisposing systemic condition assisting the diagnosis. The present case illustrates that (1) even in the absence of any predisposing risk factors, C. albicans should be considered as a possible differential diagnosis in recalcitrant uveitis, and (2) endogenous candida endophthalmitis can be a result of fungal infections from distant sites such as the toenails.Key Words: Candida albicans, Endophthalmitis, Amphotericin B, Voriconazole     

Endogenous Meningococcal Endophthalmitis with Isolated Joint Involvement in Immunocompetent Adults

Purpose: We report two cases of endogenous meningococcal endophthalmitis in immunocompetent adults presenting with unilateral ocular disease and joint involvement.

Methods: A retrospective review of two patients with endogenous endophthalmitis due to Neisseria meningitidis with associated arthropathy was conducted. The clinical presentation, investigations, treatment, and outcomes are presented.

Results: Vitreous sampling confirmed Neisseria meningitidis via polymerase chain reaction (PCR) in both cases. PCR was positive from the knee aspirate of our second case. Both patients received topical steroids and topical, intravitreal and intravenous antibiotics. Despite this, visual outcomes were poor.

Conclusions: This atypical combination of endogenous meningococcal endophthalmitis associated with meningococcal joint involvement could represent a novel pattern for the presentation of metastatic meningococcal endophthalmitis not previously described. We suggest joint aspirate PCR could be a useful adjunctive test to identify potential causative organisms in such cases where there is concurrent joint involvement in the absence of systemic features.     

Fungal Scleritis with Exudative Retinal Detachment

Purpose: To report a case of fungal scleritis associated with exudative retinal detachment.

Design: A rare case report.

Methods: Nonresolving fungal scleritis mimicking noninfective scleritis was treated with systemic and topical antifungals and low topical steroids after diagnosis was established on scleral scraping. Even after complete resolution of scleritis, exudative retinal detachment persisted.

Results: The patient was advised of a possible need to undergo vitreo retinal surgery if exudative retinal detachment persisted for more than a month after complete resolution of the scleritis component.

Conclusion: Infective scleritis must be ruled out in cases of longstanding scleritis not responding to immunosuppressives.     

Mycobacterium Bovis Endophthalmitis from BCG Immunotherapy for Bladder Cancer

Background: We report a patient who developed BCG endophthalmitis after BCG immunotherapy for bladder cancer. Comparison of this case with 2 other reported cases reveals a similar pattern of elderly, debilitated and immunocompromised patients with poor response to systemic antituberculous therapy in whom systemic steroids are used concurrently. Age and glucocorticoids are known to lead to thymic involution, reduce cell mediated immunity, and a lowering in the number of naïve T cells capable of mounting an effective defense to new infectious agents. Conclusions: Physicians should be aware of the potential for ocular complications of BCG immunotherapy in the elderly, immunocompromised, on oral steroids.     

Culture Proven Endogenous Bacterial Endophthalmitis in Apparently Healthy Individuals

Purpose: To report 7 eyes of 7 patients who were diagnosed as the cases of endogenous endophthalmitis and proved by culture reports. Though in most of the previously published series, one or more predisposing factors were present in the patients of endogenous endophthalmitis, the authors are presenting a case series of culture-proven endogenous endophthalmitis in apparently healthy and immunocompetent individuals.

Design: Retrospective noncomparative case series. All patients were diagnosed as endogenous bacterial endophthalmitis with positive vitreal culture. Variables studied were demographic characteristics, microbiology, therapeutic interventions done, final visual and anatomical outcome.

Results: Streptococcus pneumoniae was the most frequent isolate 43% (3 out of 7 eyes) followed by Staphylococcus aureus and E. coli in equal frequency 29% ( 2 each out of 7 eyes). The median time between the onset of symptoms and presentation with features of endophthalmitis to hospital was 7 days. The presenting visual acuity was less than HM (hand motions) in all cases except one, which had VA of 20/200. No single underlying predisposing condition was identifiable in any of the cases. All the cases were given intravitreal therapeutic agents (one or more doses of antibiotics and steroid) and pars plana vitrectomy was performed in 2 cases. The final visual acuity was not better than presenting VA except in 1 case, which had final VA of 20/40. Intraocular pressure was on the lower side (mean IOP 7?mmHg compared to 12?mmHg in the fellow eye). No eye was enucleated or eviscerated.

Conclusion: Though in most of the previously published literature endogenous endophthalmitis has been a metastatic ocular infection, the present study describes a series of endogenous bacterial endophthalmitis de novo in onset, without any identifiable predisposing factors. The overall age of presentation was in a younger population than in previously published series. The overall visual outcome was poor, probably due to the serious nature of disease itself and the relatively late presentation.     

Endogenous Candida endophthalmitis after induced abortion

Purpose: To report two young healthy women who developed endogenous Candida endophthalmitis after undergoing surgically induced abortion.Method: Case reports.Results: In two eyes of two patients, a diagnosis of Candida endophthalmitis was established by typical fundus appearance, positive vaginal culture, and, in one case, positive vitreous culture. After vitrectomy and intravitreal amphotericin B injection, one eye of one patient had a best-corrected visual acuity of 20/200, whereas one eye of one patient, who had systemic corticosteroid treatment before the correct diagnosis, developed recurrent retinal detachment and a best-corrected visual acuity of counting fingers.Conclusions: Induced abortion may cause endogenous Candida endophthalmitis in young healthy pregnant women. Systemic corticosteroid treatment may increase the risk of endophthalmitis.     

Successful management of presumed Candida endogenous endophthalmitis with oral voriconazole

Endogenous fungal endophthalmitis is most commonly caused by Candida species and usually occurs in patients with chronic diseases such as diabetes mellitus and renal insufficiency. Voriconazole, a broad-spectrum triazole antifungal agent, attains therapeutically significant concentrations in the vitreous cavity after systemic administration. We report, the successful management of presumed endogenous Candida endophthalmitis in a patient with multiple diseases and unstable systemic status with oral voriconazole. Though fungal endophthalmitis has been successfully treated with a combination of intravenous and intravitreal voriconazole, to the best of our knowledge this is the first report in ophthalmic literature (Medline Search) on the treatment of fungal endophthalmitis with only the oral route of administration of voriconazole.     

Salmonella Typhi Associated Endogenous Endophthalmitis: A Case Report and a Review of Literature

Aim: To report a rare case of Salmonella typhi associated endogenous endophthalmitis in an immunocompetent male and to review the available literature.

Methods: Retrospective chart review.

Results: A 28-year-old immunocompetent male presented with a 3-day-old history of pain, redness and diminished vision in his left eye. Conjunctival chemosis, corneal haze, and hypopyon were noted and yellowish exudates filled the vitreous cavity. A detailed elicitation of history revealed that patient had been treated for enteric fever that presented with diarrhea and fever, two weeks prior to current presentation. Blood and vitreous cultures grew Gram negative bacilli, identified as S. typhi. Despite intensive intravitreal and systemic antibiotic therapy, an evisceration had to be performed.

Conclusions: Endogenous endophthalmitis can be one of the rare sequelae of enteric fever and may present in the acute and relapsing phases and often times have a rapidly fulminant course with poor visual outcomes.     

Endogenous Fungal Endophthalmitis Associated with Genitourinary Procedures

Purpose: To summarize the characteristics of endogenous fungal endophthalmitis (EFE) after genitourinary procedures.

Methods: Medical records of patients diagnosed with EFE after genitourinary procedures from a single center during a 6-year period were reviewed.

Results: Nineteen eyes of 15 patients were included. The interval time between procedure to symptom was 3.6 ± 3.6 weeks. As the initial treatment, 9/19 eyes underwent primary vitrectomy and 10/19 eyes underwent intravitreal antifungal injection . Candida albicans was the pathogen in 15 of 19 eyes. Systemic treatment with itraconazole was used in all patients. LogMAR best corrected visual acuity improved from 2.2 ± 0.9 to 0.9 ± 1.2 after treatment (p = 0.002) in 15 eyes that were followed-up for an average of 4.9 ± 2.1 years.

Conclusion: Genitourinary procedure is a predisposing factor for EFE. Candida albicans is the predominant pathogen. Normative systemic and local antifungal treatments improved the final visual outcome.     

An Unusual Case of Fungal Chorioretinitis in an Immunocompetent Individual

Purpose: To describe a case of fungal chorioretinitis in a healthy individual. Design: Case report. Results: A 74-year-old immunocompetent man presented with peripheral chorioretinitis with hemorrhage in the superonasal quadrant. A retinal biopsy was performed. PAS and Gomori methenamine silver stain disclosed fungal structures identified as broad nonseptate hyphae with right-angle branches, probably belonging to the Zygomycete class. A systemic workup was initiated to seek the source of the infection with normal findings. The patient was successfully treated with intravitreous and intravenous amphotericine B. Conclusion: Nontraumatic fungal chorioretinitis can present in immunocompetent patients.     

Endogenous Cryptococcal Endophthalmitis in Immunocompetent Host: Case Report and Review of Multimodal Imaging Findings and Treatment

Purpose: To describe a case of bilateral endogenous cryptococcal endophthalmitis in an immunocompetent host and to review adjunctive ophthalmic imaging patterns and treatment.

Methods: A retrospective case report.

Results: A 45-year-old female patient with two distinct presentations of endogenous cryptococcal endophthalmitis in each eye presented initially with progressive blurred vision in the left eye, beginning more than 10 years after a craniotomy with ventriculoperitoneal shunt. Complete ophthalmic imaging was conducted and compared with data from previous literature. Administration of amphotericin-B had poorly responded; however, consolidation of fluconazole resulted in disease stabilization.

Conclusions: Bilateral intraocular cryptococcal infection can present with two distinct patterns of posterior segment findings. A review of ophthalmic imaging patterns found consistency in some characteristics of A-scan ultrasonogram and fundus fluorescein angiogram. Besides conventional treatment, voriconazole is likely to play an important role in the management of cryptococcal endophthalmitis.     

Endophthalmitis Progressing to Panophthalmitis: Clinical Features,Demographic Profile,and Factors Predicting Outcome

Purpose: To describe clinical features, demographic profile and factors predicting outcome of endophthalmitis under care progressing to panophthalmitis at a tertiary eye institute. Setting: Retrospective consecutive case series. Methods: All cases diagnosed as endophthalmitis of any etiology and undergoing treatment which progressed to panophthalmitis from January 2005 to December 2015 were included. Case records of all patients coded as endophthalmitis and then panophthalmitis were included. Data were collected regarding the clinical features, demographic profile, and treatment outcomes of those cases. Results: This study included 33 eyes of 33 patients. The mean age at presentation was 42.33 ± 21.66 years (median 40, range 5–75). The commonest etiology of endophthalmitis progressing to panophthalmitis was noted following open globe injury endophthalmitis, seen in 13/33 (39.4%) of eyes followed by endophthalmitis associated with microbial keratitis seen in 8/33 (27.3%) eyes. The time interval in days between the diagnosis of endophthalmitis and progression to panophthalmitis was 4.5 ± 3.88 days (median 3 days, range 1–14 days). Fifteen eyes denied perception of light (PL) at the time of diagnosing panophthalmitis. Culture was positive in 16 cases (48.4%), Streptococcus pneumoniae was the commonest species (4 cases) followed by Pseudomonas aeruginosa (3 cases) and Staphylococcus epidermidis (2 cases). Nine cases (27.27%) were additionally given systemic steroids along with the systemic antibiotics. The odds ratio of a favorable outcome was significantly higher when systemic steroids with antibiotics were administered (OR = 80.5, 95% C.I. 6.311026, p = 0.007), when the patient was of a younger age group (< 40 years) (OR 1.53, 95% C.I. 0.37.87, p = 0.6), when the presenting vision at diagnosis was at least light perception (OR 9.8, 95% C.I. 1.03692.7, p = 0.04), when the smear showed Gram-positive cocci (OR 6.66, 95% C.I. 1.0940.43, p = 0.03), if there was culture positivity (OR 10.5, 95% C.I. 1.1198.9, p = 0.03) and when intravenous antibiotics were administered (OR 21.43, 95% C.I. 1.11411.7, p = 0.04). Conclusions: Risk of progression of endophthalmitis to panophthalmitis is there even under care. Close observation and keen clinical examination for cases that do not respond well is essential. Intravenous antibiotics and systemic steroids should be considered in all cases of endophthalmitis that progress to panophthalmitis.     

Endoftalmitis endógena bilateral por Candida glabrata posterior a cirugía bariátrica complicada

Case reportA 43 year-old female presented with decreased visual acuity in the right eye. «Snowball-like» retinal lesions were found in both eyes on examination. Due to a lack of improvement with intravitreal antifungal empirical treatment, vitreous culture was performed and Candida glabrata was isolated. The patient then received intravitreal amphotericin B, as well as systemic treatment with caspofungin and amphotericin B lipid complex.DiscussionEndogenous fungal endophthalmitis is a sight-threatening condition. There are few reports of Candida glabrata endogenous endophthalmitis. Treatment regimens for Candida endophthalmitis include combinations of systemic and/or intravitreal antifungals, as well as vitrectomy.