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 Table of Contents  
CASE REPORTS
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 557-560

Postoperative endophthalmitis by Scedosporium apiospermum – A case report


1 Department of Vitreoretina, Dr. Shroff's Charity Eye Hospital, New Delhi, India
2 Department of Glaucoma, Dr. Shroff's Charity Eye Hospital, New Delhi, India
3 Department of Microbiology, Dr. Shroff's Charity Eye Hospital, New Delhi, India

Date of Submission28-Sep-2020
Date of Acceptance28-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Manisha Agarwal
Head of Vitreoretina Department, Dr. Shrofffs Charity Eye Hospital, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2970_20

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  Abstract 


A male patient underwent an uneventful cataract surgery. He developed fungal postoperative endophthalmitis by Scedosporium apiospermum species. This fungus is a common cause of endogenous endophthalmitis in immunocompromised patients with poor visual outcomes. We report this case to share our experience of managing fulminant postoperative endophthalmitis with an iris fungal ball in an immunocompetent patient caused by S. apiospermum.

Keywords:  Cryotherapy, fungal ball, exogenous, postoperative endophthalmitis, Scedosporium apiospermum


How to cite this article:
Agarwal M, Garg A, Pegu J, Singh S, Shah S, Gandhi A. Postoperative endophthalmitis by Scedosporium apiospermum – A case report. Indian J Ophthalmol Case Rep 2021;1:557-60

How to cite this URL:
Agarwal M, Garg A, Pegu J, Singh S, Shah S, Gandhi A. Postoperative endophthalmitis by Scedosporium apiospermum – A case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:557-60. Available from: https://www.ijoreports.in/text.asp?2021/1/3/557/320145



Postoperative endophthalmitis is the most devastating complication of any intraocular surgery. Scedosporium is a rare cause of endogenous endophthalmitis in patients with hematological malignancies and immunocompromised states.[1] The outcomes are usually poor and often an aggressive management is warranted.[2]

We report a case of postoperative endophthalmitis due to Scedosporium apiospermum and share our experience of managing it successfully with intravitreal and systemic voriconazole along with surgical intervention including transscleral cryotherapy.


  Case Report Top


A 62-year old man presented with redness and sudden painful diminution of vision in the left eye for the last 1 week. There was a history of an uneventful cataract surgery done 2 months back. There was a history of retinal detachment surgery in the right eye. No relevant systemic history.

On examination, the best-corrected visual acuity (BCVA) in the right eye was hand movement and in the left eye, counting fingers close to face (CFCF). Slit-lamp examination showed circumcorneal congestion, clear corneal incision was well apposed with no wound leak, no sutures, or corneal infiltrates. However, endoexudates were present close to the corneal wound. Anterior chamber (AC) cells grade 4+ (SUN classification) and AC flare grade 4+ with fibrin over the intraocular lens (IOL) was seen. Intraocular pressure (IOP) in the left eye was 12 mmHg. On Fundus examination, yellowish glow was present with severe vitreous haze (score 5, Nussenblatt classification)[3] with no fundus details visible. Ultrasound B-scan of the left eye showed IOL reverberations, low to moderate reflective membranous echoes in the vitreous cavity, with no evidence of posterior vitreous detachment, attached retina and normal thickness choroid.

The patient after an informed consent underwent IOL removal with core vitrectomy and intravitreal injection of vancomycin (1 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL) under local anesthesia and guarded visual prognosis. The vitreous sample and explanted IOL were sent for microbiological examination. Oral ciprofloxacin (1500 mg/day), moxifloxacin (0.5%) eye drops 8 times/day, prednisolone acetate (1%) eye drops 8 times/day, atropine 1% thrice a day along with oral prednisolone (1 mg/kg weight) on weekly tapering doses were started.

KOH mount showed hyaline hyphae with branching annelids and flat terminal conidia [Figure 1]a Subsequently topical and oral steroids were stopped. Oral voriconazole (400 mg/day) and topical voriconazole (1%) were started after baseline evaluation of liver function tests (LFT).
Figure 1: (a) KOH mount showing hyaline hyphae with branching annelids and flat terminal conidia. (b) Blood agar (white arrow), chocolate agar (black arrow) and Saboraud dextrose agar (black arrow) showing colonies with clear outer pale zone and central brownish growth with mycelial tufts suggestive of Scedosporium apiospermum. (c) Explanted IOL inoculated on blood agar showing colonies of Scedosporium apiospermum

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Vitreous sample and the explanted IOL inoculated on Blood Agar (BA), Chocolate Agar (CA) and Saboraud Dextrose Agar (SDA) showed colonies with clear outer pale zone and central brownish growth with mycelial tufts suggestive of S. apiospermum species [Figure 1]b and [Figure 1]c.

Intravitreal voriconazole (100 μg/0.1 mL) was repeated every 24 hours. Follow-up at 1-week BCVA in left eye was 20/60, N18 with normal digital tension. There was mild circumcorneal congestion, AC cells grade 2+ and hypopyon with exudates behind the iris as well as endoexudates suggestive of persistent fungal infection [Figure 2]a and [Figure 2]d. Gonioscopy showed clump of exudates over the iris encroaching the angle [Figure 2]b. A UBM was done under topical anesthesia which showed a ball of exudates behind the iris suggestive of persistent fungal hyphae [Figure 2]c.
Figure 2: (a) Slit-lamp photo showing fungal exudates behind the iris (white arrow). (b) Gonioscopy picture showing fungal exudates overlying the angle (black arrow). (c) Ultrasound Biomicroscopy showing mass lesion with high reflective borders and low to moderately reflective internal dot echoes behind the posterior surface of the iris (white arrow). (d) Slit-lamp image at presentation showing endoexudates and hypopyon. (e) Slit-lamp image, at last, follow-up showing clear cornea and anterior chamber. (f) Fundus image at last visit showing silicon oil in situ

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Intravitreal voriconazole (100 μg/0.1 mL) along with transscleral cryotherapy (double freeze thaw) to the fungal ball was performed. Multiple intravitreal injections of voriconazole were given with a frequent follow-up.

Follow-up at 3 weeks the BCVA in left eye was 20/60, N18 with low digital tension. There was persistence of AC inflammation with shrinkage in the size of the eyeball and low digital pressure. Therefore, a re-vitrectomy with silicon oil injection was performed. Oral voriconazole was stopped after 3 weeks due to deranged LFT reports. Patient received a total of 8 intravitreal voriconazole injections over a period of 3 weeks.

Patient was followed up regularly every month and was stable. On the last follow-up at 6 months the BCVA in the left eye was 20/60, N18. IOP was 11 mm of Hg with no evidence of infection, quiet AC and a well attached retina with silicone oil in situ [Figure 2]e and [Figure 2]f.


  Discussion Top


Postoperative endophthalmitis following cataract surgery is typically caused by bacterial organisms and is rarely fungal.[1] Aspergillus is the most common isolate.[1] Fungal endophthalmitis usually has a late onset of 1-2 months after surgery but in tropical countries it may present acutely. Scedosporium apiospermum is a filamentous fungus found mainly in soil, decaying vegetation and polluted water. It usually causes opportunistic infections in the immunocompromised.[2] It can also be found in manure, multiple water sources, including creeks contaminated with sewage, standing water and tide-washed coastal areas, and even in hospital potted plants.[4] Infection is caused by two species S. apiospermum and S. prolificans.[1] Scedosporium species may manifest as keratitis, sclerokeratitis, conjunctival mycetoma, orbital cellulitis and endogenous endophthalmitis.[2]

Exogenous endophthalmitis develops as a result of superficial infection, traumatic implantation of the organism or following intraocular surgery, whereas endogenous endophthalmitis occurs in immunocompromised patients with fungal septicemia.[5]

On review of literature, there are several anecdotal case reports of endogenous endophthalmitis caused by Scedosporium species [Table 1]. Zarkovic et al. have reported one case of posttraumatic endophthalmitis with a white fungal mass on iris, treated with lensectomy, vitrectomy, sector iridectomy and cryotherapy to the root of iris along with systemic and high dose of intravitreal voriconazole (200 μg/0.1 mL) with no side effects.[10] Voriconazole is said to have the lowest minimum inhibitory concentration (MIC) for Scedosporium in comparison to other drugs. Therefore, it is the preferred drug of choice for treating Scedosporium endophthalmitis.[11]
Table 1: Reported cases of endogenous endophthalmitis caused by Scedosporium apiospermum

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The endophthalmitis reported with S. apiospermum is often endogenous except for the single reported case of exogenous posttraumatic endophthalmitis reported by Zarkovic et al. However, to the best of our knowledge, an exogenous postoperative endophthalmitis by this organism is not known yet. We, herein, report the first case of postoperative endophthalmitis by S. apiospermum.

Removal of the IOL was done in the first surgery itself to provide visibility during the surgery and to remove as much nidus of infection behind the iris. An early pars plana vitrectomy with systemic and intravitreal voriconazole was done to control the infection however the fungal hyphae persisted behind the iris which is said to be the preferred site for fungal hyphae, being dark and warmer. This was treated with transscleral cryotherapy using a double freeze-thaw technique which helps to kill the fungal cells. Such eyes often develop hypotony secondary to prolonged inflammation of the ciliary body, ciliary membranes formation causing a ciliary shutdown. Once the hypotony started setting in silicone oil was injected which is said to have a dual action in such eyes- halts fungal growth and prevents phthisis bulbi secondary to hypotony.[12]


  Conclusion Top


We report this case to highlight that Scedosporium species may rarely cause postoperative endophthalmitis in immunocompetent patients. A confirmed diagnosis can only be done by strong microbiological backup and not just suspicion. Also, aggressive and early surgical intervention including transscleral cryotherapy and voriconazole treatment is the key to salvage these eyes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal.

The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cortez KJ, Roilides E, Quiroz-Telles F, Meletiadis J, Antachopoulos C, Knudsen T, et al. Infections caused by Scedosporium spp. Clin Microbiol Rev 2008;21:157-97.  Back to cited text no. 1
    
2.
McKelvie PA, Wong EY, Chow LP, Hall AJ. Scedosporium endophthalmitis: Two fatal disseminated cases of Scedosporium infection presenting with endophthalmitis. Clin Exp Ophthalmol 2001;29:330-4.  Back to cited text no. 2
    
3.
Nussenblatt RB, Palestine AG, Chan CC, Roberge F. Standardizatlon of vitreal inflammatory activity in intermediate and posterior uveitis. Ophthalmology 1985;92:467-71.  Back to cited text no. 3
    
4.
Summerbell RC, Krajden S, Kane J. Potted plants in hospitals as reservoirs of pathogenic fungi. Mycopathologia 1989;106:13-22.  Back to cited text no. 4
    
5.
McGuire TW, Bullock JD, Bullock JD, Elder BL, Funkhouser JW. Fungal endophthalmitis: An experimental study with a review of 17 human ocular cases. Arch Ophthalmol 1991;109:1289-96.  Back to cited text no. 5
    
6.
Jain A, Egbert P, McCulley TJ, Blumenkranz MS, Moshfeghi DM. Endogenous Scedosporium apiospermum endophthalmitis. Arch Ophthalmol 2007;125:1286-9.  Back to cited text no. 6
    
7.
Chen FK, Chen SD, Tay-Kearney ML. Intravitreal voriconazole for the treatment of endogenous endophthalmitis caused by Scedosporium apiospermum. Clin Exp Ophthalmol 2007;35:382-5.  Back to cited text no. 7
    
8.
Ikewaki J, Imaizumi M, Nakamuro T, Motomura Y, Ohkusu K, Shinoda K, et al. Peribulbar fungal abscess and endophthalmitis following posterior subtenon injection of triamcinolone acetonide. Acta Ophthalmol 2009;87:102-4.  Back to cited text no. 8
    
9.
Belenitsky MP, Liu C, Tsui I. Scedosporium apiospermum endopthalmitis treated early with intravitreous voriconazole results in recovery of vision. J Ophthalmic Inflammation Infection 2012;2:157-60.  Back to cited text no. 9
    
10.
Zarkovic A, Guest S. Scedosporium apiospermum traumatic endophthalmitis successfully treated with voriconazole. Int Ophthalmol 2007;27:391-4.  Back to cited text no. 10
    
11.
Girmenia C, Luzi G, Monaco M, Martino P. Use of voriconazole in treatment of scedosporium apiospermum infection: Case report. J Clin Microbiol 1998;36:1436-8.  Back to cited text no. 11
    
12.
Dave VP, Joseph J, Jayabhasker P, Pappuru RR, Pathengay A, Das T. Does ophthalmic-grade silicone oil possess antimicrobial properties? J Ophthalmic Inflamm Infect 2019;9:1-6.  Back to cited text no. 12
    


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