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Aspergillus species are ubiquitous saprophytic moulds, commonly growing in soil, stored hay, and decaying vegetation. Even though exposure to Aspergillus is universal, infection in humans is uncommon.1Aspergillus infection of ophthalmic interest usually causes keratitis or orbital cellulitis; Aspergillus endophthalmitis is a relatively rare condition that has a devastating course, with blindness as its usual outcome.2 The clinical diagnosis is difficult and the treatment is disappointing. In most cases, ocular involvement results from spread of aspergillosis infection from others organs and typically occurs in injecting drug users and in patients with immune deficiency of various causes. The leucopenia appears to be a predisposing condition for the occurrence of aspergillosis.3
We report an unusual case of bilateral endogenous Aspergillus endophthalmitis in a patient with chronic lymphocytic leukaemia in the absence of any detectable focus of aspergillosis infection elsewhere in the body and that showed a good response to specific systemic therapy.
A 51 year old white man with a previous diagnosis of chronic lymphocytic leukaemia and use of an immunosuppressive agent was referred to ophthalmological examination because of a red eye, pain, and blurred vision in his right eye. The clinical picture worsened and diagnosis of endophthalmitis was made. Intravitreous amphotericin B injection was performed and did not control the case. Culture of vitreous fluid was positive for Candida. This eye was eviscerated because of increasing pain, progressive infection, and poor response to treatment. Posterior histopathological study was conclusive for Aspergillus endophthalmitis in the right eye (Fig 1B and 2). At the same time, fundus examination of the left eye showed two subretinal exudatives lesion located at nasal and inferior retina with retinal oedema associated with superficial haemorrhages (Fig 1A). The vitreous was clean and the central macula remained intact. Visual acuity was 6/6 in this eye.
Vitreous biopsy or culture may yield negative results in some cases of early intraocular Aspergillus endophthalmitis.3 We did not take a vitreous biopsy of the left eye, since we already had the diagnosis in the right eye and the visual acuity was 6/6. This eye was treated with intravenous amphotericin B and oral itraconazole with a good result. The patient remained stable with resolution of the lesions and no focus of systemic aspergillosis was found.
Fungal endophthalmitis is uncommon. In most of the cases Candida is the causal organism.4,5 Few cases of Aspergillus endophthalmitis in a patient with chronic lymphocytic leukaemia have been described,4 and according to the literature endogenous Aspergillus endophthalmitis represents a manifestation of disseminated aspergillosis, usually a fatal infection.6,7 This case is unusual because it is bilateral and no focus of systemic aspergillosis was found.
The cases of intraocular inflammation secondary to Aspergillus are more common in the central macula and have a poor prognosis.1 In our case the localisation of the chorioretinitis in the left eye was out of the posterior area and the patient’s visual acuity remained 6/6.
The major antifungal agent used in aspergillosis is amphotericin B. Without host immune competence, treatment is rarely effective. Penetration of intravenous amphotericin B into the vitreous cavity of the normal or inflamed eye is poor.8,9 The azole compounds have been used to reduce the significant toxicity and enhance the efficacy of intravenous amphotericin B; oral fluconazole is the drug of choice because it has excellent penetration in central nerve system and vitreous.1 Itraconazole may be used. Intravitreous amphotericin B and vitrectomy have given the best results in the treatment of these cases.2 Our patient received intravenous amphotericin B and oral itraconazole and this therapy was sufficient to control the infection.
This case shows that Aspergillus endophthalmitis should be considered in all patients with immune deficiency even in the absence of systemic aspergillosis. Treatment with intravenous amphotericin B may be able to control these cases and should be attempted more often.