CHRONIC POSTOPERATIVE FUNGAL ENDOPHTHALMITIS CAUSED BY TRICHOSPORON ASAHII Ronald W. Slocumb, MD, Susan G. Elner, MD, Edward F. Hall, MD
Purpose: To describe a patient with chronic postoperative fungal endophthalmitis caused by Trichosporon asahii. Methods: A retrospective case report. Results: An 82-year-old woman was found to have culture-proven T. asahii chronic fungal endophthalmitis with initial symptoms beginning 18 months after uneventful phacoemulsification with intraocular lens implantation. Successful treatment was achieved with pars plana vitrectomy, capsulectomy, and oral voriconazole without explantation of the intraocular lens. Conclusion: This is the first reported case of chronic postoperative T. asahii endophthalmitis. Our patient was successfully treated with pars plana vitrectomy, capsulectomy, and oral voriconazole without explantation of the intraocular lens. RETINAL CASES & BRIEF REPORTS 4:366–367, 2010
than to amphotericin B or fluconazole.2 There have been two reported cases of Trichosporon-related postsurgical endophthalmitis in seemingly immunocompetent patients. However, both cases were acute onset after ocular surgery.3,4 We report the first case of chronic postoperative T. asahii endophthalmitis occurring more than 1 year after cataract extraction with posterior chamber intraocular lens (IOL) implantation in an immunocompetent patient.
From the Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan.
T
richosporon spp., a spore-forming fungal organism usually found in soil and fresh water, has also been recovered from normal skin, nail, and oral microflorae and is known to cause white piedra, hypersensitivity pneumonia, and invasive infections in immunocompromised patients.1Trichosporon beigelii, previously Trichosporon cutaneum, has been considered the main species of Trichosporon isolated in humans. However, the genus has recently been revised, and six different species are now considered to cause human disease: Trichosporon asahii, Trichosporon asteroides, T. cutaneum, Trichosporon inkin, Trichosporon mucoides, and Trichosporon ovoides.1 T. asahii is the species most frequently involved in disseminated infections in immunocompromised patients. T asahii is the most common species of Trichosporon isolated from deep sites with many strains showing better susceptibility to voriconazole
Case Report An 82-year-old woman was referred to our institution for clinical suspicion of chronic endophthalmitis in the right eye. She had undergone uneventful phacoemulsification with IOL implantation in her right eye 3 years earlier. Eighteen months after this cataract surgery, she had presented to her outside ophthalmologist with blurred vision and pain in the right eye. She was found to have anterior segment inflammation and was treated with topical steroids with improvement in symptoms. Two similar episodes occurred during the next year with the most recent occurring 2 months before presentation to our institution. Visual acuity measured at that time was 20/400 in the right eye. There was 4+ anterior chamber cell and flare, hypopyon, and posterior chamber ‘‘clouding’’ with ‘‘granulomas’’ on the capsule. Laboratory evaluation, including purified protein derivative (PPD), antinuclear antibody (ANA), rapid plasma reagin (RPR), angiotensin converting enzyme (ACE), rheumatoid factor (RF), lysozyme, and complete blood count (CBC), was unrevealing. The patient reported no history of recent travel, exposure to, or history of tuberculosis, tick bites, cat bites/scratches, or ingestion of raw meat. Her medical history was significant for hypertension, arthritis, and a right-sided stroke 10 years earlier.
No authors have any proprietary interest in any of the subject matter in this article. Reprint requests: Susan G. Elner, MD, Kellogg Eye Center, 1000 Wall Street, Ann Arbor, MI 48105; e-mail: selnerOmed. umich.edu
366
367
CHRONIC POSTOPERATIVE FUNGAL ENDOPHTHALMITIS On presentation, she was using Lotemax three times per day in the right eye. Initial best-corrected visual acuity was 20/40 in the right eye and 20/25 in the left eye. Intraocular pressure was normal in each eye. Slit-lamp examination of the right eye showed mild inferior pigmented keratitic precipitates, a deep and quiet anterior chamber, posterior synechiae, a posterior chamber IOL with inferior posterior capsular haze and focal areas of dense white precipitate, and trace cell in the anterior vitreous. Dilated fundus examination of the right eye revealed mild vitreous cell but was otherwise unremarkable. Complete ophthalmic examination of the left eye was unremarkable. Based on the high clinical suspicion of chronic infectious endophthalmitis, the patient underwent pars plana vitrectomy with extensive posterior capsulectomy, leaving no visible posterior capsular infiltrates. The IOL was not explanted. An undiluted vitreous specimen was obtained and immediately plated onto blood, chocolate, Sabaroud, Laked blood, and fungal culture media. Laked blood agar plates were placed in anaerobic bags. Intravitreal vancomycin (1 mg/0.1 mL) was injected into the vitreous cavity through the pars plana at the end of the surgery. Vitreous washings were prepared similarly and sent for bacterial and fungal cultures. Slides were prepared for bacterial and fungal stains. A direct smear of the vitreous sample revealed fungal elements, and the cultures of both undiluted and vitreous washings were positive for T. asahii. Anaerobic cultures were negative. After consultation with the infectious disease service, the patient was started on 400 mg oral voriconazole 2 times per day for 1 day followed by 200 mg twice a day. The patient had an uneventful postoperative course, and 6 weeks postoperatively, voriconazole was discontinued. Three months later, visual acuity had stabilized at 20/40 in the affected eye without recurrent intraocular inflammation or explantation of the IOL.
Discussion Infectious endophthalmitis occurs in roughly 0.1% of patients undergoing cataract surgery. Postoperative endophthalmitis is often categorized by time of onset, acute onset if occurrence is within 6 weeks of surgery and chronic if later. The clinical presentation of our patient was typical for a chronic postoperative endophthalmitis. The most common organisms that cause chronic postoperative endophthalmitis include Propionibacterium acnes, coagulase-negative Staphylococcus, and rarely, fungi such as Aspergillus and Candida.5 Postoperative fungal endophthalmitis may have an early or late onset ranging from 48 hours to 7 months.6 Our patient presented 18 months postoperatively, and vitreous smears and cultures implicated T. asahii, a rare fungus typically associated with immunocompromised patients, as the etiologic agent. Although there is no specific evidence of T. asahii colonization
of the human eyelids in the literature, it is a wellknown transient colonizer of the human skin, respiratory tract, and gastrointestinal system.1 The most likely source of our patient’s infection was from her own local microflora and probably occurred from an intraocular inoculation at the time of her cataract surgery. Predisposing conditions for fungal infection include chronic ocular surface disease, contact lens use, long-term use of topical or systemic steroids, trauma, and absolute or relative immunosuppression because of systemic disease such as HIV/AIDS, renal failure, and diabetes mellitus.6 Our patient had none of these predisposing factors. T. asahii has been shown to be the most common Trichosporon species to be isolated from deep sites in a hospital-based study.2 Thus, intraocular infection with T. asahii seems plausible, although only rarely reported to date. Only two other cases of Trichosporon-related post-surgical endophthalmitis in immunocompetent patients have been described, both of which occurred acutely after surgery.3,4 To the best of our knowledge, this is the first reported case of chronic postoperative T. asahii endophthalmitis. Key words: chronic fungal endophthalmitis, Trichosporon asahii, Trichosporon asahii endophthalmitis, postoperative endophthalmitis, fungal endophthalmitis.
References 1. Gueho E, Improvisi L, de Hoog GS, Dupont B. Trichosporon in humans: a practical account. Mycoses 1994;37:3–10. 2. Araujo Ribeiro M, Alastruey-Izquierdo A, Gomez-Lopez A, Rodriguez-Tudela JL, Cuenca-Estrella M. Molecular identification and susceptibility testing of Trichosporon isolates from a Brazilian hospital. Rev Iberoam Micol 2008;25:221–225. 3. Spirn MJ, Roth DB, Yarian DL, Green SN. Postoperative fungal endophthalmitis caused by Trichosporon beigelii resistant to amphotericin B. Retina 2003;23:404–405. 4. Sheikh HA, Mahgoub S, Badi K. Postoperative endophthalmitis due to Trichosporon cutaneum. Br J Ophthalmol 1974;58: 591–594. 5. Benz MS, Scott IU, Flynn HW Jr, Unonius N, Miller D. Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol 2004;137: 38–42. 6. Narang S, Gupta A, Gupta V, et al. Fungal endophthalmitis following cataract surgery: clinical presentation, microbiological spectrum, and outcome. Am J Ophthalmol 2001;132: 609–617.
Purpose: To describe a patient with chronic postoperative fungal endophthalmitis caused by Trichosporon asahii. Methods: A retrospective case report. Results: An 82-year-old woman was found to have culture-proven T. asahii chronic fungal endophthalmitis with initial symptoms beginning 18 months after uneventful phacoemulsification with intraocular lens implantation. Successful treatment was achieved with pars plana vitrectomy, capsulectomy, and oral voriconazole without explantation of the intraocular lens. Conclusion: This is the first reported case of chronic postoperative T. asahii endophthalmitis. Our patient was successfully treated with pars plana vitrectomy, capsulectomy, and oral voriconazole without explantation of the intraocular lens. RETINAL CASES & BRIEF REPORTS 4:366–367, 2010
than to amphotericin B or fluconazole.2 There have been two reported cases of Trichosporon-related postsurgical endophthalmitis in seemingly immunocompetent patients. However, both cases were acute onset after ocular surgery.3,4 We report the first case of chronic postoperative T. asahii endophthalmitis occurring more than 1 year after cataract extraction with posterior chamber intraocular lens (IOL) implantation in an immunocompetent patient.
From the Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan.
T
richosporon spp., a spore-forming fungal organism usually found in soil and fresh water, has also been recovered from normal skin, nail, and oral microflorae and is known to cause white piedra, hypersensitivity pneumonia, and invasive infections in immunocompromised patients.1Trichosporon beigelii, previously Trichosporon cutaneum, has been considered the main species of Trichosporon isolated in humans. However, the genus has recently been revised, and six different species are now considered to cause human disease: Trichosporon asahii, Trichosporon asteroides, T. cutaneum, Trichosporon inkin, Trichosporon mucoides, and Trichosporon ovoides.1 T. asahii is the species most frequently involved in disseminated infections in immunocompromised patients. T asahii is the most common species of Trichosporon isolated from deep sites with many strains showing better susceptibility to voriconazole
Case Report An 82-year-old woman was referred to our institution for clinical suspicion of chronic endophthalmitis in the right eye. She had undergone uneventful phacoemulsification with IOL implantation in her right eye 3 years earlier. Eighteen months after this cataract surgery, she had presented to her outside ophthalmologist with blurred vision and pain in the right eye. She was found to have anterior segment inflammation and was treated with topical steroids with improvement in symptoms. Two similar episodes occurred during the next year with the most recent occurring 2 months before presentation to our institution. Visual acuity measured at that time was 20/400 in the right eye. There was 4+ anterior chamber cell and flare, hypopyon, and posterior chamber ‘‘clouding’’ with ‘‘granulomas’’ on the capsule. Laboratory evaluation, including purified protein derivative (PPD), antinuclear antibody (ANA), rapid plasma reagin (RPR), angiotensin converting enzyme (ACE), rheumatoid factor (RF), lysozyme, and complete blood count (CBC), was unrevealing. The patient reported no history of recent travel, exposure to, or history of tuberculosis, tick bites, cat bites/scratches, or ingestion of raw meat. Her medical history was significant for hypertension, arthritis, and a right-sided stroke 10 years earlier.
No authors have any proprietary interest in any of the subject matter in this article. Reprint requests: Susan G. Elner, MD, Kellogg Eye Center, 1000 Wall Street, Ann Arbor, MI 48105; e-mail: selnerOmed. umich.edu
366
367
CHRONIC POSTOPERATIVE FUNGAL ENDOPHTHALMITIS On presentation, she was using Lotemax three times per day in the right eye. Initial best-corrected visual acuity was 20/40 in the right eye and 20/25 in the left eye. Intraocular pressure was normal in each eye. Slit-lamp examination of the right eye showed mild inferior pigmented keratitic precipitates, a deep and quiet anterior chamber, posterior synechiae, a posterior chamber IOL with inferior posterior capsular haze and focal areas of dense white precipitate, and trace cell in the anterior vitreous. Dilated fundus examination of the right eye revealed mild vitreous cell but was otherwise unremarkable. Complete ophthalmic examination of the left eye was unremarkable. Based on the high clinical suspicion of chronic infectious endophthalmitis, the patient underwent pars plana vitrectomy with extensive posterior capsulectomy, leaving no visible posterior capsular infiltrates. The IOL was not explanted. An undiluted vitreous specimen was obtained and immediately plated onto blood, chocolate, Sabaroud, Laked blood, and fungal culture media. Laked blood agar plates were placed in anaerobic bags. Intravitreal vancomycin (1 mg/0.1 mL) was injected into the vitreous cavity through the pars plana at the end of the surgery. Vitreous washings were prepared similarly and sent for bacterial and fungal cultures. Slides were prepared for bacterial and fungal stains. A direct smear of the vitreous sample revealed fungal elements, and the cultures of both undiluted and vitreous washings were positive for T. asahii. Anaerobic cultures were negative. After consultation with the infectious disease service, the patient was started on 400 mg oral voriconazole 2 times per day for 1 day followed by 200 mg twice a day. The patient had an uneventful postoperative course, and 6 weeks postoperatively, voriconazole was discontinued. Three months later, visual acuity had stabilized at 20/40 in the affected eye without recurrent intraocular inflammation or explantation of the IOL.
Discussion Infectious endophthalmitis occurs in roughly 0.1% of patients undergoing cataract surgery. Postoperative endophthalmitis is often categorized by time of onset, acute onset if occurrence is within 6 weeks of surgery and chronic if later. The clinical presentation of our patient was typical for a chronic postoperative endophthalmitis. The most common organisms that cause chronic postoperative endophthalmitis include Propionibacterium acnes, coagulase-negative Staphylococcus, and rarely, fungi such as Aspergillus and Candida.5 Postoperative fungal endophthalmitis may have an early or late onset ranging from 48 hours to 7 months.6 Our patient presented 18 months postoperatively, and vitreous smears and cultures implicated T. asahii, a rare fungus typically associated with immunocompromised patients, as the etiologic agent. Although there is no specific evidence of T. asahii colonization
of the human eyelids in the literature, it is a wellknown transient colonizer of the human skin, respiratory tract, and gastrointestinal system.1 The most likely source of our patient’s infection was from her own local microflora and probably occurred from an intraocular inoculation at the time of her cataract surgery. Predisposing conditions for fungal infection include chronic ocular surface disease, contact lens use, long-term use of topical or systemic steroids, trauma, and absolute or relative immunosuppression because of systemic disease such as HIV/AIDS, renal failure, and diabetes mellitus.6 Our patient had none of these predisposing factors. T. asahii has been shown to be the most common Trichosporon species to be isolated from deep sites in a hospital-based study.2 Thus, intraocular infection with T. asahii seems plausible, although only rarely reported to date. Only two other cases of Trichosporon-related post-surgical endophthalmitis in immunocompetent patients have been described, both of which occurred acutely after surgery.3,4 To the best of our knowledge, this is the first reported case of chronic postoperative T. asahii endophthalmitis. Key words: chronic fungal endophthalmitis, Trichosporon asahii, Trichosporon asahii endophthalmitis, postoperative endophthalmitis, fungal endophthalmitis.
References 1. Gueho E, Improvisi L, de Hoog GS, Dupont B. Trichosporon in humans: a practical account. Mycoses 1994;37:3–10. 2. Araujo Ribeiro M, Alastruey-Izquierdo A, Gomez-Lopez A, Rodriguez-Tudela JL, Cuenca-Estrella M. Molecular identification and susceptibility testing of Trichosporon isolates from a Brazilian hospital. Rev Iberoam Micol 2008;25:221–225. 3. Spirn MJ, Roth DB, Yarian DL, Green SN. Postoperative fungal endophthalmitis caused by Trichosporon beigelii resistant to amphotericin B. Retina 2003;23:404–405. 4. Sheikh HA, Mahgoub S, Badi K. Postoperative endophthalmitis due to Trichosporon cutaneum. Br J Ophthalmol 1974;58: 591–594. 5. Benz MS, Scott IU, Flynn HW Jr, Unonius N, Miller D. Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol 2004;137: 38–42. 6. Narang S, Gupta A, Gupta V, et al. Fungal endophthalmitis following cataract surgery: clinical presentation, microbiological spectrum, and outcome. Am J Ophthalmol 2001;132: 609–617.
