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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 561-563

Positive syphilis serology in a case of endogenous candida endophthalmitis posing a diagnostic dilemma


1 Department of Retina and Uvea, Sadguru Netra Chikitsalya and Postgraduate Institute of Ophthalmology, Jankikund, Chitrakoot, Madhya Pradesh, India
2 Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission17-Aug-2020
Date of Acceptance19-Jan-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Alok Sen
Department of Retina and Uvea Services, Sadguru Netra Chikitsalya and Postgraduate Institute of Ophthalmology, Jankikund, Chitrakoot, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2674_20

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  Abstract 


Endogenous candida endophthalmitis (ECE) being a rare entity can often be misdiagnosed particularly in a seropositive debilitated patient. Ocular syphilis may have protean clinical manifestations and may be difficult to diagnose in absence of typical clinical manifestations. A high index of suspicion based on the clinical picture and imaging features may aid in differentiating these clinical entities. We report a case of ECE in a diabetic patient with a positive syphilis serology, the co-existence of which posed a diagnostic dilemma. We discuss the pragmatic approach and management for such a perplexing scenario.

Keywords: Candida endophthalmitis, endogenous endophthalmitis, OCT, syphilis, vitrectomy


How to cite this article:
More A, Sen A, Kohli G, Shenoy P, Gupta A. Positive syphilis serology in a case of endogenous candida endophthalmitis posing a diagnostic dilemma. Indian J Ophthalmol Case Rep 2021;1:561-3

How to cite this URL:
More A, Sen A, Kohli G, Shenoy P, Gupta A. Positive syphilis serology in a case of endogenous candida endophthalmitis posing a diagnostic dilemma. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:561-3. Available from: https://www.ijoreports.in/text.asp?2021/1/3/561/320005



Fungal infections account for 11.1%–17.4% of endogenous endophthalmitis (EE) of which Candida albicans is the most prevalent.[1] There has been a constant escalation in the rate of syphilis from 11.2 per 1,00,000 population in 2005 to 31.4 in 2017.[2] The diagnosis of both candida EE and ocular syphilis requires a high index of suspicion. We discuss the approach and management in a rare case scenario of endogenous Candida endophthalmitis (ECE) in a patient with positive syphilis serology.


  Case Report Top


A 59-year-old, recently diagnosed diabetic man, presented with painful diminution of vision in the right eye (RE) for 20 days. He had received systemic antibiotics for his foot ulcer and was started on antidiabetic medications for sugar control, before the onset of vision loss. On evaluation, the patient had a healing foot ulcer with granulation tissue with no purulent discharge. His vision in the RE was 1/60 and 6/6 in the left eye (LE). Anterior segment evaluation of the RE showed circumciliary congestion, nongranulomatous keratic precipitates, and cellular reaction of 3+. Fundus examination showed vitreous haze of grade 3 with a few cotton-ball like fluffy vitreous exudates. A yellowish-white retinal lesion with indistinct margins was noted adjoining the fovea [Figure 1]a. The LE findings were unremarkable. Due to the vitritis minute, details of fundus fluorescein angiography (FFA) were not discernable; however, late phase angiogram revealed profuse disc leakage, vessel wall staining, and hyperfluorescence at the site of the lesion [Figure 1]b. Optical coherence tomography (OCT) through the lesion showed vitreous cells, a thickened posterior hyaloid, focal hyperreflective aggregates on the retinal surface with backshadowing, and a localized elevation of the retinal pigment epithelium (RPE) with a breach in the RPE-Bruch's membrane complex [Figure 2]a and [Figure 2]b.
Figure 1: (a) Fundus photo of the right eye at presentation showing presence of a small yellowish-white lesion adjoining the fovea (arrowhead) along with vitritis. (b) Late phase FFA at presentation showing hyperfluorescence temporal to fovea (solid arrow), vessels wall leakage, and a hot disc. (c) One week post vitrectomy the lesion shows consolidation with decrease in its lateral extent (dotted arrow)

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Figure 2: (a) RE OCT showing typical “rain-cloud” sign (asterisk) with thickened posterior hyaloid (solid arrow) and preretinal hyperreflective aggregates obscuring underlying retina (dotted arrow). (b) RE OCT through fovea showing breach in the retinal pigment epithelium-Bruch's membrane complex (arrowhead), with indistinct retinal layers. (c) OCT at 1-week post PPV, at the area of penetration the retinal layers (arrowhead) show decrease in the retinal layer alteration, regularisation of retinal contour marking resolution on the lesion (dotted circle)

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Based on the patient's history and the presenting clinical picture, FFA and OCT findings, a provisional diagnosis of EE was made. Patient's fasting and postprandial blood sugars were 92 mg% and 152 mg%, respectively. His complete blood count was within normal limits, ESR 36 mm. He was HIV negative with a mantoux of 10 mm. His foot ulcer was already in the healing stage with good granulation tissue and the culture from the wound was negative. The urine and blood cultures were also negative. However,  Treponema pallidum Scientific Name Search emagglutination Assay (TPHA) and Venereal Disease Research Laboratory test (VDRL) (1:64) both were positive, suggesting the possibility of ocular syphilis.

This diagnostic dilemma prompted us to perform a diagnostic pars plana vitrectomy (PPV), which was done without the use of any antifungal drugs in any form. Considering positive syphilis serology and history of high-risk behavior, the patient was also evaluated by an internist. Ceftriaxone was administered 2 mg daily as an alternative to penicillin since the latter was not available.[3] The vitreous culture done on sabouraud dextrose agar and chrome agar came by the 7th-day post vitrectomy was positive for Candida albicans. By the time the vitreous culture reports were available the retinal lesion had already started to show signs of resolution. Hence, the intravitreal and systemic antifungal drugs were deferred [Figure 1]c and [Figure 2]c. At 8 weeks the vision had improved to 6/9. The 4 months follow-up visit had maintained vision 6/9, OCT showed complete resolution of the lesion, and FAF showed central hypo autofluorescence with surrounding hyper autofluorescence suggestive of scaring [Figure 3]a and [Figure 3]b.
Figure 3: (a): Four months following vitrectomy, the lesion showed scaring with a stretched internal limiting membrane (solid arrow). (b): Fundus autofluorescence image at four months, hypo-autofluorescence with surrounding hyper-autofluorescence (dotted arrow)

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  Discussion Top


Establishing a clinical diagnosis of EE in the early stages remains challenging considering the nonspecific findings which can bear similarities to and remain indistinct from other infectious uveitis.[4] The relatively lower prevalence of fungal EE and difficulty in isolating the organism from blood cultures makes it difficult to make a definitive diagnosis.[5]

The temporal association of ocular symptoms following treatment of foot ulcer, clinical presentation of dense vitritis with presence of cotton ball-like vitreous exudates and focal chorioretinitis were all suggestive of the possibility ECE in our patient.[6] The OCT picture in our patient showing pre-retinal hyperreflective material with shadowing of retinal layers beneath the lesion has been described as a “rain cloud” sign by Invernizzi et al. in ECE.[7] Similar features on OCT have also been reported in two other recent reports.[8]

Our OCT findings represent the extension of the candida infections into the vitreous cavity and correlate well with the classically described three-dimensional retina based vitreal fluff ball which is suggestive for ECE.[9]

The FFA showed late leakage from chorioretinitis site; this corroborated with elevation of RPE and break in RPE at the site of lesion on OCT, further confirming the extension of candida infection from choroid into the vitreous cavity.

In our case, the positive VDRL and TPHA tests were suggestive of syphilis, while the clinical features and OCT findings were indicative of a fungal EE. This predicament prompted us to perform a diagnostic PPV which identified Candida albicans favoring the diagnosis of ECE.

Ocular syphilis being a great masquerade can present with protean manifestations of which retinochoroiditis is one of the quintessential posterior segment presentations.[10] Focal retinitis and fluffy vitreous exudates as seen in our case are not typically seen in ocular syphilis. However, since both the VDRL and TPHA were positive we treated the patient with intravenous ceftriaxone for 14 days.

Following PPV there was an observable improvement in media clarity with the consolidation of the lesion. We withheld the treatment with intravitreal and/or systemic antifungals as the retinal lesion was healing following vitrectomy. Uncontrolled diabetes and systemic antibiotics may have led to transient candidemia and ECE in our case. Rao et al. in a histopathological study noted that late in the course of candida EE the organisms are predominantly located in vitreous with presence of little or no organism in retina or choroid.[11] This could explain the role of PPV in facilitating resolution of ECE in our case without adjuvant antifungal agents.


  Conclusion Top


Our case probably represents a case of ECE that responded well to PPV while a positive syphilis serology was an incidental finding; however, the possibility of both existing together cannot be ruled out.

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.
Sharma S, Padhi TR, Basu S, Kar S, Roy A, Das T. Endophthalmitis patients seen in a tertiary eye care centre in Odisha: A clinico-microbiological analysis. Indian J Med Res 2014;139:91-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Syphilis-2017 Sexually Transmitted Diseases Surveillance [Internet]. Cdc.gov. 2020. Available from: https://www.cdc.gov/std/stats17/syphilis.htm#:~:text=Overall%2C%20in%202017%2C%2070.4%25, (Tables%2031%20and%2032).  Back to cited text no. 2
    
3.
Spornraft-Ragaller P, Abraham S, Lueck C, Meurer M. Response of HIV-infected patients with syphilis to therapy with penicillin or intravenous ceftriaxone. Eur J Med Res 2011;16:47-51.  Back to cited text no. 3
    
4.
Schiedler V, Scott I, Flynn H, Davis J, Benz M, Miller D. Culture-proven endogenous endophthalmitis: Clinical features and visual acuity outcomes. Am J Ophthalmol 2004;137:725-31.  Back to cited text no. 4
    
5.
Brod R, Flynn H, Clarkson J, Pflugfelder S, Culbertson W, Miller D. Endogenous Candida endophthalmitis. Ophthalmology 1990;97:666-74.  Back to cited text no. 5
    
6.
Oude Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C, et al. Ocular manifestations of candidemia. Clin Infect Dis 2011;53:262-8.  Back to cited text no. 6
    
7.
Invernizzi A, Symes R, Miserocchi E, Cozzi M, Cereda M, Fogliato G, et al. Spectral domain optical coherence tomography findings in endogenous candida endophthalmitis and their clinical relevance. Retina 2018;38:1011-8.  Back to cited text no. 7
    
8.
Bansal R, Menia N, Sharma S. Fungal retinitis following influenza virus type A (H1N1) infection. Indian J Ophthalmol 2019;67:1483-4.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Rodríguez-Adrián L, King R, Tamayo-Derat L, Miller J, Garcia C, Rex J. Retinal lesions as clues to disseminated bacterial and candidal infections: Frequency, natural history, and etiology. Medicine (Baltimore) 2003;82:187-202.  Back to cited text no. 9
    
10.
Agarwal M, Ranjan R, Paul L, Sharma D. Syphilitic uveitis misdiagnosed as viral retinitis—A misleading history. J Ophthal Inflamm Infect 2018;8:22.  Back to cited text no. 10
    
11.
Rao N, Hidayat A. Endogenous mycotic endophthalmitis: Variations in clinical and histopathologic changes in candidiasis compared with aspergillosis. Am J Ophthalmol 2001;132:244-51.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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