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Insidious Candida Endophthalmitis In Intravenous Drug Abuse
Julia Castronova, OD
VA San Diego 3350 La Jolla Village Dr, San Diego, CA
Abstract
Intravenous drug abuse is a well-known risk factor for endogenous
endophthalmitis. Initial presentation can vary, making the diagnosis difficult. This
case report of candida endophthalmitis in a young and healthy heroin user
demonstrates these difficulties.
I. Case History
 27 year old white female
 Chief Complaint:
o First time patient to the eye clinic
o Presented as an emergency with:
 Red eye OD
 Daily right temporal headaches with “pressure” behind OD
 Mild pain on eye movement, photophobia and occasional
blurred vision OD for the past week
 Sudden onset of floaters OD starting approximately two
weeks prior to exam
o Patient denied recent trauma or infection
o No personal or family history of autoimmune or collagen-vascular
diseases
o No history of HIV, gonorrhea, or syphilis
o No recent rash, back pain, joint pain, cough, fever, tick exposure,
recent travels or hiking
 Ocular History:
o None
 Medical History:
o Anxiety
o Depression
o Chronic pain from metatarsal fracture
o Acne
o Cervical dysplasia
 Medications:
o Buspirone HCL 10mg
o Lorazepam 0.5mg
o Gabapentin 300mg
o Naproxen 375mg
o Percocet 325mg
o Clindamycin Phosphate 1% topical solution
II. Pertinent findings
 Clinical:
o Best Corrected Distance Acuity 20/25 OD, 20/20 OS
o Extraocular motilities were unrestricted in all gazes with pain OD
noted on superior and superior right gaze
o Anterior Segment
 Mild sectoral injection of superior nasal bulbar conjunctiva
with mild pinguecula and no palpable nodules OD
 Conjunctiva was clear OS
 Cornea was clear OD/OS
 Anterior Chamber was deep and quiet, (-)cells or flare
OD/OS
 Vitreous syneresis, (-)vitreous cells or pigment OD/OS
 2.5% Phenylephrine was instilled:
 The deep vessels minimally blanched
o Posterior pole was unremarkable OD/OS
 Physical:
o Tenderness on palpation of superior nasal lid OD
o No facial scars or erythema
o No preauricular or sub-mandibular node swelling upon palpation
III. Differential diagnosis
 Primary/leading:
o Episcleritis
 Others:
o Uveitis
o Scleritis
IV. Diagnosis and discussion
 Uveitis was initially on the list of differential diagnoses due to symptoms
of photophobia and a sudden increase in floaters.
o There were no signs of keratic precipitates or blood cells in the
anterior chamber or vitreous, and no signs of retinal inflammatory
lesions.
o There was no history of sarcoidosis, syphilis, Lyme disease or
tuberculosis.
 Scleritis was considered higher on the list of differential diagnoses due to
the minimal blanching of deep vessels after instillation of 2.5%
Phenylephrine.
o The patient does not fit the appropriate age demographics for
scleritis and was not complaining of severe eye pain as would be
expected.
o Patient not diagnosed or symptomatic for any autoimmune or
inflammatory diseases including rheumatoid arthritis, systemic
lupus erythematosus, inflammatory bowel disease or ankylosing
spondylitis.
 Episcleritis was high on the differentials as the only presenting sign was
sectoral injection of the bulbar conjunctiva, and that patient only
experienced moderate discomfort. Patient’s symptoms appeared to be
disproportionate to clinical findings.
V. Treatment, management



Fluorometholone acetate 0.1% QID OD only
Naproxen 375mg PO BID
Pt was counseled to return to clinic immediately if symptoms worsen
I. One week follow up:
 Patient did not start taking the medication as prescribed until 2 days
prior to this exam
o Reports improvement in redness OD
o Now experiencing extreme photophobia with pressure headache
behind OD
o Decreased vision with increased floaters OD since last visit
 No history of raw meat consumption
 Lived with a cat 8 months ago
 No history of immune suppression or recent
surgeries/instrumentation
II. Pertinent findings
 Clinical:
o Best Corrected Distance Acuity 20/200+1 OD, 20/20 OS
o Anterior Segment
 Moderate sectoral injection of superior nasal bulbar
conjunctiva with mild pinguecula and no palpable nodules OD
 Lids, cornea, anterior chamber, vitreous and conjunctiva were
clear OS
 Mild corneal edema with grade 4+ fine keratic precipitates OD
 Anterior Chamber Grade 4+ cells and flare with grade 1+ fibrin
hypopyon OD
 Posterior synechia 360 degrees at the pupillary border OD
 4+ Vitreous cells OD
 1% Cyclopentolate, 2.5% Phenylephrine and 1% Tropicamide
were instilled:
 The deep vessels minimally blanched
 Partial scattered break of posterior synechia
o Unobtainable views of the posterior pole due to dense vitreous
inflammation OD
 Physical:
o Tenderness on palpation of superior nasal lid OD
 Laboratory studies:
o HLA B27: Negative
o ACE: Within normal limits
o LYME EIA SCREEN: Negative
o RPR: Negative
o HIV ANTIBODY SCREEN: Negative
o HSV TY-1 IGG AB: Positive
o HSV TY-2 IGG AB: Negative
o CBC: Within normal limits
o Blood cultures: Negative
o TOXOPLASMA ANTIBODY PANEL: Negative
 Imaging:
o Chest Radiograph: Within normal limits
o Echocardiogram: Within normal limits
o B-Scan performed showed no retinal detachment and large
amounts of vitreous debris in the retina OD
III. Differential diagnosis
 Primary/leading:
o Severe panuveitis OD
 Others:
o Toxoplasmosis
o Sarcoidosis
o Tuberculosis
o Bechet’s Disease
o Endophthalmitis
IV. Diagnosis and discussion
o Panuevitis was the primary diagnosis due to the presence of severe, diffuse
inflammation of both the anterior and posterior segments.
o Toxoplasmosis was on the list of differentials for etiologies of panuveitis due
to history of exposure to cats.
o Toxoplasmosis antibody panel was ordered to rule out previous or
current infection and was found to be negative.
o Sarcoidosis and Tuberculosis were on the list of differentials due to the
symptoms of headache.
o However, this patient did not present with large mutton-fat keratic
precipitates.
o These differentials were lower on the list because of negative results
on lab work for inflammatory etiology.
o Chest radiography was ordered to rule this out and was found to be
normal.
o Bechet’s Disease was also on the list as a known cause of panuveitis.
o This patient did not fit the appropriate racial demographics for
Bechet’s Disease or present with history of genital or oral ulcers.
o Concern for endophthalmitis was lower at this point based on history.
o There was no history of immune suppression, recent surgeries,
trauma or illness.
IV. Treatment and Management
 Referred to Ophthalmology General Clinic that day and prescribed:
o Prednisolone acetate 1% 1gtt q1h OD
o Cyclopentolate 1% 1gtt QID OD
o Began systemic work-up given the severity of presentation
 4 days later:
o While taking Prednisolone acetate, there was minimal
improvement of the anterior chamber reaction and a further
decrease in acuity to HM at 6ft OD. Vitreous cells, vitreous
snowballs and one white retinal lesion superior to the optic nerve
were noted OD.
o Patient revealed a history of intranasal and IV drug use including
heroin, methamphetamine, and cocaine.
 She does not share needles and cleans her skin with alcohol
before injecting.
o Patient was diagnosed with subacute endophthalmitis with fungal
and parasitic infectious etiologies as possible differentials.
 Echocardiogram was ordered to rule out endocarditis and
was found to be within normal limits.
o Para plana vitrectomy OD and vitreous core biopsy with culture
and injection of intravitreal antibiotics (amphoterecin 5mcg/0.1cc,
ceftazidime 2.25mg/0.1cc, vancomycin 1mg/0.1cc) was performed
that day.
 1 day follow-up status post vitrectomy:
o Following vitrectomy, there was a significant improvement in
anterior chamber inflammation but no improvement in acuity.
Vitreous cells and vitreous snowballs remained with three white
retinal lesions noted superior to the optic nerve OD.
o Vitreous cultures were growing yeast species on the bacterial
plates (4 colonies) with a pattern consistent with Candida and
elevated candida titers by serology (IgM, IgG).
 Organism is sensitive to Fluconazole, Voriconazole, and 5Flucytosine.
o Infectious disease was consulted, and they recommended
Fluconazole 600 mg/day as Voriconazole is not reliably absorbed.
o Prednisolone acetate 1% 1 gtt QID OD
o Cyclopentolate 1% 1 gtt QID OD
o Vigamox 1 gtt OD QID
o To date, inflammation has been slowly improving but with no
recovery in acuity.
VI. Conclusion
o Fungal endophthalmitis can be found in intravenous drug users.
o There is typically a delay in the onset of symptoms, with the infection
developing slowly over weeks.
o The classic finding is small, white inflammatory exudates at the retinavitreous interface or a “string of pearls” pattern of vitreous strands.
o A diagnostic vitrectomy is usually recommended before committing a patient
to a potentially toxic treatment regimen.
o Less common but often initial presenting ocular manifestations of candidiasis
can include episcleritis, scleritis, keratic precipitates, and hypopyon.
o The presentation of panuveitis in otherwise healthy patients and the
tendency of patient’s not to reveal history of IVDU may cause many patients
to be misdiagnosed, with a resultant delay in treatment and poor visual
prognosis.
o Diagnosis and treatment were made more difficult with our case due to the
unique presentation. The patient also likely did not experience as much pain
and discomfort because of her drug abuse or concurrent usage of Percocet
for chronic pain.
o Inflammatory etiologies may be of more concern initially, but an extensive
inflammatory/infectious work-up is necessary when the inflammation is not
responding or worsening in response to initial steroid or antibiotic
treatments.
o When episcleritis presents with symptoms more severe than clinical signs or
a quick progression of ocular condition occurs, a history of intravenous drug
abuse should be asked and fungal endophthalmitis considered in a list of
differential diagnoses.
References
1. Connell PP, O’neill EC, Amirul Islam FM, et al. Endogenous endophthalmitis
associated with intravenous drug abuse: seven-year experience at a tertiary
referral center. Retina 2010;30;1721-5.
2. Kim RW, Juzych MS, Eliott D. Ocular manifestations of injection drug use.
Infect Dis Clin N Am 2002;16:607-22.
3. Martinez-Vazquez C, Fernandez-Ulloa J, Bordon J, et al. Candida albicans
endophthalmitis in brown heroin addicts: response to early vitrectomy
preceded and followed by antifungal therapy. Infect Dis Clin N Am
1998;27:1130-3
4. Sorrell TC, Dunlop C, Collignon PJ, et al. Exogenous ocular candidiasis
associated with intravenous heroin abuse. Br J Ophthalmol 1986;68:841-5.