Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Endogenous Candida albicans Endophthalmitis Following Spontaneous Abortion and IUD Removal

Rishi R. Doshi, MD; Jon D. Wender, MD; J. Michael Jumper, MD; Steven R. Sanislo, MD; Theodore Leng, MD, MS

Abstract

The authors report a rare case of a 32-year-old woman who developed endogenous Candida albicans endophthalmitis following spontaneous abortion and removal of a contraceptive intrauterine device. Considerations regarding diagnosis and management are presented based on a review of the literature.

Abstract

The authors report a rare case of a 32-year-old woman who developed endogenous Candida albicans endophthalmitis following spontaneous abortion and removal of a contraceptive intrauterine device. Considerations regarding diagnosis and management are presented based on a review of the literature.

Endogenous Candida albicans Endophthalmitis Following Spontaneous Abortion and IUD Removal

From the Department of Ophthalmology (RRD, JDW, JMJ), California Pacific Medical Center, San Francisco; West Coast Retina (JDW, JMJ), San Francisco; and Byers Eye Institute at Stanford (SRS, TL), Stanford University School of Medicine, Palo Alto, California.

Supported by The Pacific Vision Foundation, San Francisco, California, and The Heed Ophthalmic Foundation, Cleveland, Ohio. The supporters had no role in study design, data collection, analysis, or interpretation, writing of the report, or the decision to submit for publication. All authors had an equal role in these endeavors.

Dr. Sanislo is a consultant for Oraya Therapeutics. The remaining authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Theodore Leng, MD, MS, Byers Eye Institute at Stanford, 2452 Watson Court, Palo Alto, CA 94303. E-mail: tedleng@stanford.edu

Received: January 26, 2011
Accepted: October 28, 2011
Posted Online: December 16, 2011

Introduction

Candida albicans is the most common organism implicated in endogenous fungal endophthalmitis. Although usually occurring in patients who are immunocompromised or debilitated, this entity may affect otherwise healthy women of reproductive age. Approximately 1 in 5 to 6 non-pregnant women will have a positive vaginal culture for C. albicans. Hormonal changes in pregnancy predispose women to fungal colonization and this number rises to almost 1 in 3.1 Despite the high rate of colonization, fungal septicemia rarely occurs. Risk factors for the systemic dissemination of fungal organisms include treatment with systemic antibiotics and the presence of a contraceptive intrauterine device (IUD).

We report a rare case of C. albicans fungal endophthalmitis following spontaneous abortion and removal of an IUD. Although this patient ultimately received definitive therapy, this case demonstrates the difficulty often involved in the diagnosis and treatment of this condition.

Case Report

A 32-year-old woman with no significant medical or ocular history presented with an acute onset of blurred vision, photophobia, and new floaters in her right eye. One week prior, she had undergone a dilation and curettage procedure with removal of IUD for spontaneous abortion. Examination of the right eye revealed a visual acuity of counting fingers, 2+ anterior chamber cell with non-granulomatous keratic precipitate, and 2+ vitritis with a yellow-white lesion approximately 600 μm in diameter protruding through the macula into the vitreous cavity (Fig. 1). Examination of the left eye was unremarkable. Fluorescein angiography demonstrated mild hypofluorescence corresponding with the macular lesion without leakage. Optical coherence tomography demonstrated a retinochoroidal lesion with breakthrough into the vitreous (Fig. 2). The patient was hospitalized for presumed endogenous fungal endophthalmitis and treated with intravenous fluconazole and intravitreal injections of vancomycin 1 mg/0.1 mL and amphotericin B 5 mcg/0.1 mL. The decision was made to include a vancomycin injection to cover possible gram-positive endophthalmitis (although it was less likely than a fungal infection). A vitreous culture for bacteria and fungus, aqueous polymerase chain reaction analysis for herpes simplex virus, varicella zoster virus, cytomegalovirus, fungi, and multiple blood cultures during her hospital course were all negative. A work-up including Quantiferon Gold, chest computed tomography, angiotensin converting enzyme, lysozyme, and HIV antibody was without abnormality with the exception of a positive Quantiferon Gold test for latent tuberculosis. Despite a repeat intravitreal injection of amphotericin B and vancomycin 1 week after presentation, the vitreous lesion increased in size to approximately 600 × 1,000 μm and the patient was taken to the operating room for a diagnostic and therapeutic vitrectomy. Cultures of the vitreous from surgery were negative, but cytology demonstrated budding yeast identified by cytology as C. albicans. The patient continued oral fluconazole for 2 weeks after surgery and was placed on treatment for latent tuberculosis. Five months after presentation, she underwent repeat vitrectomy with membrane peel for macular pucker. Visual acuity in her right eye improved to 20/50, limited by a macular scar (Fig. 3).

Color fundus photograph of the right eye demonstrating a yellow-white chorioretinal lesion protruding through macula and into the vitreous cavity. A thick area of vitritis overlies the inferior temporal arcade, partially obscuring it.

Figure 1. Color fundus photograph of the right eye demonstrating a yellow-white chorioretinal lesion protruding through macula and into the vitreous cavity. A thick area of vitritis overlies the inferior temporal arcade, partially obscuring it.

Optical coherence tomography scan of the right eye. A retinochoroidal lesion can be seen breaking through the retina into the vitreous cavity. It is of high reflectance, causing decreased choroidal reflectivity. There is a speckled appearance to the vitreous, signifying vitritis.

Figure 2. Optical coherence tomography scan of the right eye. A retinochoroidal lesion can be seen breaking through the retina into the vitreous cavity. It is of high reflectance, causing decreased choroidal reflectivity. There is a speckled appearance to the vitreous, signifying vitritis.

Color fundus photograph and optical coherence tomography scan of the right eye after repeat vitrectomy with membrane peel for macular pucker. Visual acuity is 20/50, limited by a macular scar.

Figure 3. Color fundus photograph and optical coherence tomography scan of the right eye after repeat vitrectomy with membrane peel for macular pucker. Visual acuity is 20/50, limited by a macular scar.

Discussion

Removal of retained fetal material or IUDs following spontaneous or elective abortion has rarely been reported to result in endogenous endophthalmitis with C. albicans. In six cases reported in the literature from 1987 to 2002, the onset of symptoms occurred from 3 days to 3 weeks after surgical intervention for abortion.2–5 Vitreous culture was positive for C. albicans in only two cases, and negative in all others; diagnosis was otherwise made by vaginal culture in two cases, blood culture in one case, and presumptively in 1 case. All cases but one were treated with intravitreal and/or systemic antifungal agents with or without pars plana vitrectomy. The last case was treated only with systemic antibiotics and resulted in enucleation. Visual acuity outcomes for cases with antifungal therapy ranged from 20/30 to counting fingers, with improved outcomes favoring patients undergoing earlier treatment (Table).

Cases of Fungal Endophthalmitis After Spontaneous or Induced Abortiona

Table: Cases of Fungal Endophthalmitis After Spontaneous or Induced Abortion

Our case illustrates the difficulty often involved in diagnosis and treatment of this condition. When faced with inconclusive results from blood and vitreous cultures, a high index of suspicion must be maintained with further diagnostic options including vaginal culture and cytological analysis of a surgically obtained vitreous specimen. Although systemic antifungal therapy may be adequate treatment in cases with only chorioretinitis or minimal vitritis, significant vitritis warrants surgical intervention with vitrectomy and consideration of adjunctive intravitreal amphotericin B.6 Because timely intervention may improve visual outcome, the presence of blurred vision and floaters after surgical manipulation of the female reproductive tract should prompt early evaluation for endogenous fungal endophthalmitis.

References

  1. Potasman I, Leibovitz Z, Sharf M. Candida sepsis in pregnancy and the postpartum period. Rev Infect Dis. 1991;13:146–149. doi:10.1093/clinids/13.1.146 [CrossRef]
  2. Chang TS, Chen WC, Chen HS, Lee HW. Endogenous Candida endophthalmitis after two consecutive procedures of suction dilatation and curettage. Chang Gung Med J. 2002;25:778–782.
  3. Chen SJ, Chung YM, Liu JH. Endogenous Candida endophthalmitis after induced abortion. Am J Ophthalmol. 1998;125:873–875. doi:10.1016/S0002-9394(98)00052-X [CrossRef]
  4. Haskjold E, von der Lippe B. Endogenous Candida endophthalmitis: report of two cases. Acta Ophthalmol (Copenh). 1987;65:741–744. doi:10.1111/j.1755-3768.1987.tb07074.x [CrossRef]
  5. Sikic J, Vukojevic N, Katusic D, Saric B. Bilateral endogenous Candida endophthalmitis after induced abortion. Croat Med J. 2001;42:676–678.
  6. Smiddy WE. Treatment outcomes of endogenous fungal endophthalmitis. Curr Opin Ophthalmol. 1998;9:66–70. doi:10.1097/00055735-199806000-00012 [CrossRef]

Cases of Fungal Endophthalmitis After Spontaneous or Induced Abortiona

CitationCaseAge (Y)Presenting VAVaginal CultureBlood CultureVitreous CultureAntifungal TreatmentFinal VA
Haskjold and Von der Lippe, 1987127CFNegativeNegativeNoneEnucleation
225CFNegative; histology of placental and fetal tissue demonstrated fungusC. albicansNegativeIV amphotericin and flucytosine20/40
Chen et al., 199812120/1200C. albicansNegativePPV with IVT amphotericin20/200
224CFC. albicansC. albicansPPV with IVT amphotericin, oral fluconazoleCF
Sikic et al., 200113120/400 OD, 20/200 OSC. albicansNegative; positive serologyNegativeBilateral PPV with IVT amphotericin, systemic antifungals20/60 OD, 20/30 OS
Chang et al., 2002124LPNegativeC. albicansPPV with IVT amphotericin, oral fluconazole20/25
Current report132CFNegativeNegative; positive cytologyPPV with IVT amphotericin, IV fluconazole20/80
Authors

From the Department of Ophthalmology (RRD, JDW, JMJ), California Pacific Medical Center, San Francisco; West Coast Retina (JDW, JMJ), San Francisco; and Byers Eye Institute at Stanford (SRS, TL), Stanford University School of Medicine, Palo Alto, California.

Supported by The Pacific Vision Foundation, San Francisco, California, and The Heed Ophthalmic Foundation, Cleveland, Ohio. The supporters had no role in study design, data collection, analysis, or interpretation, writing of the report, or the decision to submit for publication. All authors had an equal role in these endeavors.

Dr. Sanislo is a consultant for Oraya Therapeutics. The remaining authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Theodore Leng, MD, MS, Byers Eye Institute at Stanford, 2452 Watson Court, Palo Alto, CA 94303. E-mail: tedleng@stanford.edu

10.3928/15428877-20111208-02

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