Retina Today - Medicine Plus Surgery Treats an Unusual Case of Fungal Endophthalmitis (October 2017)

摘要

Extreme morning sickness, or hyperemesis gravidarum, is a complication of pregnancy characterized by severe nausea and vomiting, weight loss, and even dehydration. Whereas mild cases of hyperemesis gravidarum can be treated with dietary changes, rest, and antacids, more severe cases can require hospitalization and intravenous nutrition. The following case report describes a young pregnant woman with fungal endophthalmitis in the setting of candidemia from fungal endocarditis after receiving total parenteral nutrition (TPN). AT A GLANCE • Ophthalmologic findings of C. albicans endophthalmitis have a strong association with disseminated candidiasis, especially in the setting of predisposing factors. • In this case report, prompt vitrectomy and intravitreal injection of amphotericin led to rapid visual recovery. CASE REPORT A 31-year-old black woman, at 24 weeks gestational age, was admitted to the San Antonio Military Medical Center for hyperemesis gravidarum requiring TPN. She returned 2 weeks later with complaints of blurry vision in her right eye (OD). The patient had no previous ocular history or history of intravenous drug use. HIV test performed earlier in the pregnancy was negative. On presentation, visual acuity (VA) was 20/70 OD and 20/20 in her left eye (OS). Her intraocular pressure (IOP) was 19 mm Hg OD and 20 mm Hg OS, and there was no relative afferent pupillary defect. The external examination was unremarkable. Anterior chamber examination exhibited 1+ cell OD. Funduscopic examination OD revealed a solitary fluffy white juxtafoveal lesion that measured 1 disc diameter with slight elevation. Overlying vitritis with small intraretinal hemorrhage was seen adjacent to the lesion (Figure 1). On scleral depression, numerous snowballs were present in the inferior vitreous. Figure 1. Fundus photo OD. A superior juxtafoveal lesion is visible, and optic disc edema is apparent. Ocular coherence tomography (OCT) of the macula revealed vitreomacular adhesion (VMA) with a hyperreflective lesion superior to the fovea. Central fundus thickness (CFT) was 552 μm (Figure 2). A systemic evaluation was performed, including echocardiogram, which revealed vegetation on the patient’s tricuspid valve. Initial blood cultures were negative for bacterial or fungal microorganisms, but Fungitell assay (Beacon Diagnostics Laboratory) was positive for the presence of fungus. The patient had no previous cardiac history, but she did have a remote history of bacteremia from a central line infection. Noncontrast magnetic resonance imaging of the brain and orbits was normal. Figure 2. OCT macula 512x128 horizontal (A) and vertical (B) section OD. Figure 3. B-scan OD vertical anterior-posterior (A) and 9 o’clock transverse (B) sections with extensive vitritis. The patient was treated with intravenous liposomal amphotericin B and daptomycin, in consultation with infectious disease specialists, due to concern for concurrent native-valve endocarditis and the previous history of a central line infection. Extensive lab workup was unremarkable for rapid plasma reagin, cytomegalovirus (CMV), toxoplasmosis, immunoglobulin M and G antibodies, Brucella, histoplasmosis, Cryptococcus, and Coxiella antigen. The next day, the patient’s VA had worsened to 20/200 OD. Examination revealed worsening papillary optic disc edema and vitritis. B-scan demonstrated worsening vitritis (Figure 3). Due to the extent of the vitritis and the location of the retinitis, the patient underwent pars plana vitrectomy with removal of the hyaloid. Intravitreal amphotericin B 5 μg was administered after vitrectomy. The results of vitreous biopsy were positive for Candida albicans. Figure 4. Postoperative day 5. OCT macula 512x128 horizontal (A) and vertical (B) sections OD. Figure 5. Postoperative week 3. OCT macula 512x128 horizontal (A) and vertical (B) sections OD. On po