CURVULARIA LUNATA ENDOPHTHALMITIS AFTER PENETRATING OCULAR TRAUMA Sergio Jaramillo, MD, Clara L. Varon, MD
Purpose: To report a case of Curvularia lunata endophthalmitis that responded to amphotericin B and itraconazole Methods: Observational case report of one patient with C. lunata endophthalmitis after penetrating ocular injury with vegetable material. Results: One young adult male patient presented with visual loss after penetrating ocular trauma with vegetable material. Biomicroscopy revealed keratitis and secondary endophthalmitis. Vitreous cultures after vitrectomy were positive for C. lunata and Staphylococcus epidermidis. Patient responded well to intravitreal amphotericin B and moxiﬂoxacin. Conclusion: Fungal endophthalmitis should be suspected after trauma with vegetable material. Curvularia lunata may produce endophthalmitis and keratitis. Amphotericin B and itraconazole should be considered suitable agents for its treatment. RETINAL CASES & BRIEF REPORTS 7:315–318, 2013
included topical moxiﬂoxacin and prednisone. Ten days after the initial surgery, the patient was referred to our institution for endophthalmitis management. A sutured corneal wound was found in the superonasal quadrant with anterior chamber cells, ﬁbrinoid membranes, hypopyon, and blood. Computed tomography of the orbit and ultrasonography were performed to rule out the presence of an intraocular foreign body. Best-corrected visual acuity was hand movement. An aqueous humor tap was done with intravitreal injection of 0.1 mL of vancomycin and 0.1 mL of ceftazidime. The patient did not improve and developed a corneal ulcer with melting of tissue around the corneal wound and sutures. Hypopyon, hyphema, and ﬁbrinoid
From the Retina and Vitreous Department, Fundacion Oftalmologica de Santander Clinica Carlos Ardila Lulle, Bucaramanga, Colombia.
urvularia species is a dematiaceous fungi rarely reported to cause endophthalmitis after ocular trauma, cataract surgery, or keratitis.1–4 Around 44% of fungal endophthalmitis may develop by contiguous spread of advanced fungal keratitis.5 Trauma associated with organic matter is considered an important risk factor for keratitis development. Final visual outcomes of fungal endophthalmitis after open-globe injuries have shown the poorest results.5 We report a case of Curvularia lunata endophthalmitis after penetrating ocular trauma with organic material.
Case Report A 17-year-old patient suffered ocular trauma on his left eye with a fruit of oil palm tree. Initial best-corrected visual acuity in this eye was 20/80. A penetrating corneal wound with traumatic cataract and hyphema was found. Anterior chamber lavage, lensectomy, and corneal suture were performed elsewhere. Postoperative treatment None of the authors have any ﬁnancial/conﬂicting interests to disclose. Reprint requests: Sergio Jaramillo, MD, Fundacion Oftalmologica de Santander Clinica Carlos Ardila Lulle, Bucaramanga, Colombia; e-mail: [email protected]
Fig. 1. Initial aspect of the eye with corneal melting in the superonasal quadrant secondary to keratitis and endophthalmitis.
RETINAL CASES & BRIEF REPORTS´ 2013 VOLUME 7 NUMBER 4
Fig. 2. Hyaline septated hyphae of vitreous specimen.
membranes on the pupil prevented from determining the status of the retina (Figure 1). Aqueous humor cultures reported Staphylococcus epidermidis and the presence of hyaline, septated hyphae (Figure 2). A pars plana vitrectomy was done 3 days later with injection of intravitreal vancomycin 0.1 mL, ceftazidime 0.1 mL, and amphotericin B 5 mg/0.1 mL. Vitreous specimen was sent for microbiological examination. Cyclitic membranes were found, as well as preretinal hemorrhages. A conjunctival ﬂap was necessary to cover the area of corneal melting (Figure 3). Postoperative medications included hourly topical moxiﬂoxacin, atropine twice daily, and topical amphotericin B every 2 hours. Systemic medications included vancomycin and oral itraconazole 100 mg twice daily. Antibiotic susceptibility tests for the staphylococcus reported sensibility for moxiﬂoxacin and gatiﬂoxacin. Three days later, the patient received another intravitreal injection of moxiﬂoxacin and amphotericin B. Vitreous and aqueous cultures conﬁrmed the presence of C. lunata and S. epidermidis. The macroscopic appearance was that of a ﬂuffy grayish black colony (Figure 4), and the microscopic appearance showed the typical curved spores (Figure 5). We decided to use 3 consecutive intravitreal injections of amphotericin B and moxiﬂoxacin every 2 days because of the increased clearance after vitrectomy. The patient had a good evolution with a ﬁnal best-corrected visual acuity of 20/80 with +10.25 diopter aphakic refraction. Figure 6 shows
the ﬁnal aspect of the eye with the corresponding VISANTE OCT (Carl Zeiss Meditec, Dublin, CA).
Fig. 3. Postoperative aspect 1 week postsurgery.
Fig. 4. Macroscopic appearance of fungal culture.
Discussion Dematiaceous fungal endophthalmitis has a very poor prognosis.1–4,6,7 Some publications have shown a weak action of amphotericin B against C. lunata. We report a case of C. lunata endophthalmitis associated with corneal abscess that responded well with intravitreal amphotericin B and oral itraconazole. This case highlights the importance of aqueous or vitreous tap for diagnosis. In this eye, prompt antifungal treatment was installed according to the microbiologic results. Optimal treatment of C. lunata endophthalmitis is unknown. Reported therapies include systemic itraconazole,1–3 voriconazole,7 or posaconazole7 associated with topical natamycin1,3 or amphotericin B and intravitreal injections of amphotericin B2,7 or voriconazole.1 Intravitreal amphotericin B must be used cautiously because of
CURVULARIA LUNATA ENDOPHTHALMITIS
Fig. 5. Curved spores of Curvularia lunata.
reported intraocular toxicity from highly concentrated preparations.8 There are few cases published in the literature about C. lunata endophthalmitis. To our knowledge, this is the ﬁrst report of an infection associated with organic material. The other cases have been associated with cataract surgery and a ﬁshing hook.1–4,6,7 It is always important to suspect fungal infections when dealing with contaminated cases with dirt or vegetable material. Key words: amphotericin B, Curvularia, endophthalmitis, moxiﬂoxacin, itraconazole. References
Fig. 6. Final aspect of the eye with corresponding VISANTE OCT image that shows anterior synechiae of the iris and ﬁbrous tissue ﬁlling the previous corneal defect.
1. Berbel RF, Casella AM, de Freitas D, Höﬂing-Lima AL. Curvularia lunata endophthalmitis. J Ocul Pharmacol Ther 2011;27:535–537. 2. Kaushik S, Ram J, Chakrabarty A, et al. Curvularia lunata endophthalmitis with secondary keratitis. Am J Ophthalmol 2001;131:140–142. 3. Pathengay A, Shah GY, Das T, Sharma S. Curvularia lunata endophthalmitis presenting with a posterior capsular plaque. Indian J Ophthalmol 2006;54:65–66. 4. Sisk RA, Smiddy WE, Dubovy SR, Miller D. Chronic Curvularia lunata endophthalmitis following cataract extraction. Retin Cases Brief Rep 2009;3:438–439.
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5. Wykoff CC, Flynn Jr HW, Miller D, et al. Exogenous fungal endophthalmitis: microbiology and clinical outcomes. Ophthalmology 2008;115:1501–1507, 1507.e1–2. 6. Rummelt V, Ruprecht KW, Boltze HJ, et al. Chronic Alternaria alternata endophthalmitis following intraocular lens implantation. Arch Ophthalmol 1991;109:178.
7. Ehlers JP, Chavala SH, Woodward JA, Postel EA. Delayed recalcitrant fungal endophthalmitis secondary to Curvularia. Can J Ophthalmol 2011;46:199–200. 8. Payne JF, Keenum DG, Sternberg P, et al. Concentrated intravitreal amphotericin B in fungal endophthalmitis. Arch Ophthalmol 2010;128:1546–1550.