Decreased Vision Due to Fungus in an IV Drug User

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Image Source: The New England Journal of Medicine©

Why is it important to highlight a case of fungal endophthalmitis?

Because untreated fungal endophthalmitis can lead to blindness.

Once a rare sight, the incidence of fungal endophthalmitis has increased in the past few years, particularly in the last two decades, especially in immunocompromised individuals.

Fungal endophthalmitis can be either endogenous or exogenous. In the latter, the causative fungus enters, most commonly, through trauma to the eye.
Below is an example of endogenous fungal endophthalmitis.

A 34-year-old man presents to the ophthalmology clinic with complaints of pain and decreased vision in his right eye for one week. He is an intravenous drug abuser and reports being a known case of hepatitis C.

The visual acuity was 20/400 in the right eye. On the slit-lamp examination, the ophthalmologist noticed inflammation in the anterior chamber and conjunctival injection in the right eye. Indirect ophthalmoscopy revealed vitreous haze, and lesions on the retina and optic nerve (Panel A, arrow). The examination of the left eye was normal, along with the normal visual activity of 20/20.

Serological investigations were unremarkable with negative blood cultures.

Transthoracic echocardiography showed no evidence of vegetations, ruling out infective endocarditis secondary to IV drug use.

Fungal endophthalmitis was suspected

The patient was started on oral and intravitreal voriconazole (an antifungal). Despite being compliant with the treatment, the vitreous lesions didn’t resolve; therefore, vitrectomy was performed.

Intraoperatively, a white mass was incised and removed, which was adherent to the optic nerve. The mass measured 4 mm by 3 mm by 1 mm. Panel C shows the mass in the anterior chamber just before removal.

The incised mass was sent for histopathological evaluation. Gomori methenamine silver staining revealed a necrotizing granuloma with fungal yeast forms suggestive of candida species. (Panel D, arrow)

Postoperatively, his visual acuity improved to 20/30. Oral voriconazole treatment was continued for six weeks postoperatively.

At the 6-month follow-up, his vision was stable with no evidence of recurrence.

Although fungal endophthalmitis is a rare disease, recently, diagnosis of fungal ophthalmitis is surfacing more often than expected, probably due to advancements in the diagnostic modalities. Moreover, Candida species have seen to be predominating, and aspergillus is the second most common.

Symptoms vary according to the part of the eye affected. The causative fungus may cause vitritis, iritis, anterior uveitis, and endophthalmitis.

Why use Gomori methenamine silver stain?
Fungal organisms do not stain well on Gram stain does not stain fungus well enough; therefore, Giemsa or Gomori methenamine silver stain is used to spot fungal organisms.

Patients may lose vision due to fungal endophthalmitis.

Thus, early diagnosis and prompt treatment are required for a better prognosis. Otherwise, even after the treatment, the visual acuity may not improve.

References

John R. Chancellor, M. a. (2020, May 07). Fungal Endophthalmitis. Retrieved from The New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMicm1911882

Sridhar, Jayanth & Flynn, Harry & Kuriyan, Ajay & Miller, Darlene & Albini, Thomas. (2013). Endogenous fungal endophthalmitis: Risk factors, clinical features, and treatment outcomes in mold and yeast infections. Journal of ophthalmic inflammation and infection. 3. 60. 10.1186/1869-5760-3-60.

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Dr. Arsia Parekh
Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.

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