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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.