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Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 564-565

Commentary: A curious case of double dilemma

1 Department of Uveitis, Aravind Eye Hospital, Pondicherry, India
2 Department of Uveitis, Aravind Eye Hospital, Chennai, Tamil Nadu, India

Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Bala Murugan Sivaraman
Aravind Eye Hospital, B.12, Staff Quarters, Thavalakuppam, Pondicherry - 605 007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_259_21

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How to cite this article:
Sivaraman BM, Anthony E. Commentary: A curious case of double dilemma. Indian J Ophthalmol Case Rep 2021;1:564-5

How to cite this URL:
Sivaraman BM, Anthony E. Commentary: A curious case of double dilemma. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:564-5. Available from: https://www.ijoreports.in/text.asp?2021/1/3/564/320000

The authors had brought forward a dicey case with an ambiguous diagnosis.[1] However, the workup of the case, including the basic evaluation for uveitis and endophthalmitis, appears to be quite important in this enigmatic scenario. The elementary task of evaluating the predisposing factor, which had set the stage for the problem, such as diabetes and its adequate control is very significant in this case.

Is it syphilis?

Current guidelines for syphilis state to order both treponemal and nontreponemal tests because although the Treponema pallidum hemagglutination (TPHA) test is more specific, it remains positive for life. Hence Venereal Disease Research Laboratory (VDRL) titers are very important to detect active syphilis infection.[2] Baseline titers of VDRL and their follow-up with repeat titers to decide on end point of treatment could have helped the clinician, if syphilis was proposed as the etiology.[3] Considering the initial presentation of panuveitis with active retinitis lesions, positive VDRL and TPHA tests, and good response to systemic antibiotics, possibility of ocular syphilis could be ruled out. Syphilitic punctate inner retinitis, which presents with punctate retinitis lesions, vitritis, and superficial retinal precipitates, is often misdiagnosed as other causes of retinitis.[4],[5] Interestingly the vitreous culture showed growth of candida, but the resolution of retinitis following pars plana vitrectomy in the absence of antifungal treatment can also raise the possibility of contamination of the vitreous sample, although bacterial contamination of vitreous sample is quite common.[6]

Is it candida endophthalmitis?

The point favoring the diagnosis of candida endophthalmitis is the characteristic clinical picture and the optical coherence tomography (OCT) finding, namely, the “rain cloud sign.” However, this sign could have been repeated and captured elegantly, similar to Invernizzi et al.[7] Previously in a report, Lavine and Mititelu have described hypofluorescence at the level of subfoveal scar in candida endophthalmitis. Fundus autofluorescence imaging, in this case, could have helped assess the retinal pigment epithelium status, at the level of various active lesions.[8] Further OCT studies in different etiologies needs to be done to confirm and validate the characteristic association of “rain cloud sign” to candida endophthalmitis.

What is the role of diabetes as a predisposing factor for candida endophthalmitis?

Active steps taken to control diabetes in this case are extremely important in the management plan. Diabetes is a predisposing factor for candida endophthalmitis, and it causes low pH in the vitreous, leading to the formation of microabscess and localization of infection primarily in the vitreous.[9] Endogenous candida endophthalmitis with no definite evidence of candidemia and negative culture is not uncommon. Transient candidemia with negative blood culture can also lead to endophthalmitis. Candida has also been demonstrated from a diabetic foot culture in a patient diagnosed with candida endophthalmitis.[10] In particular, appropriate culture from the diabetic foot ulcer could have acted as a pointer in the diagnostic approach.

How was fluorescein angiography important in this case?

Superficial preretinal lesions are more suggestive of latent inflammation and deeper lesions, which were more of active inflammatory focus with characteristic fluorescence pattern.[11] However, the fluorescein angiographic findings, in this case, could have been clearly described, at the level of lesions at the vitreoretinal interface, during the early, middle, and late phases in order to assess the activity. Despite vessel wall staining, the active vascular leakage is not classically made out.

What is the role of pars plana vitrectomy in managing candida endophthalmitis?

As the rate of detection of candida in culture is low, diagnosis of candida endophthalmitis is mainly clinical.[12] Performing a vitreous culture and making diagnosis vitreous tap or vitreous biopsy would have sufficed. The whole purpose of doing a core vitrectomy, in this case, is both diagnostic and therapeutic, because of very high suspicion of endogenous endophthalmitis from the beginning. However, Gram and KOH (potassium hydroxide) staining of the sample could have helped in the early detection of candida. Therapeutic and diagnostic vitrectomy is known to significantly reduce inflammation in infectious uveitis.[13] Early vitrectomy has resulted in better visual outcome in few cases of endophthalmitis also.[14] However, a definitive role of early vitrectomy in the treatment of candida endophthalmitis is very debatable. It has shown to reduce the risk of retinal detachment but does not alter the visual outcome much.[12] As there was a strong suspicion of endogenous endophthalmitis, possibly candida, from the beginning, prophylactic intravitreal antibiotics and antifungal treatment could have been considered.

However, a strong clinical suspicion, characteristic OCT findings, and positive vitreous candida culture in this patient with diabetes were all strong points in favor of candida endophthalmitis. A brilliant response to early vitrectomy without any antifungal treatment is a very interesting point to note in this case. This case also demonstrates very well the beauty of correlation of clinical findings with investigatory reports and response to treatment.

  References Top

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.  Back to cited text no. 1
  [Full text]  
Todd J, Munguti K, Grosskurth H, Mngara J, Changalucha J, Mayaud P, et al. Risk factors for active syphilis and TPHA seroconversion in a rural African population. Sex Transm Infect 2001;77:37-45.  Back to cited text no. 2
Clement ME, Okeke NL, Hicks CB. Treatment of syphilis: A systematic review. JAMA 2014;312:1905-17.  Back to cited text no. 3
Agarwal M, Ranjan R, Paul L, Sharma D. Syphilitic uveitis misdiagnosed as viral retinitis—A misleading history. J Ophthalmic Inflamm Infect 2018;8:22.  Back to cited text no. 4
Wickremasinghe S, Ling C, Stawell R, Yeoh J, Hall A, Zamir E. Syphilitic punctate inner retinitis in immunocompetent gay men. Ophthalmology 2009;116:1195-200.  Back to cited text no. 5
Rezende FA, Qian CX, Sapieha P. Evaluation of the vitreous microbial contamination rate in office-based three-port microincision vitrectomy surgery using Retrector technology. BMC Ophthalmol 2014;14:58.  Back to cited text no. 6
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
Lavine JA, Mititelu M. Multimodal imaging of refractory Candida chorioretinitis progressing to endogenous endophthalmitis. J Ophthalmic Inflamm Infect 2015;5:54.  Back to cited text no. 8
Rao NA, Hidayat AA. 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. 9
Brod RD, Flynn HW Jr, Clarkson JG, Pflugfelder SC, Culbertson WW, Miller D. Endogenous Candida endophthalmitis: Management without intravenous amphotericin B. Ophthalmology 1990;97:666-74.  Back to cited text no. 10
Cho M, Khanifar AA, Chan RP. Spectral-domain optical coherence tomography of endogenous fungal endophthalmitis. Retin Cases Brief Rep 2011;5:136-40.  Back to cited text no. 11
Sallam A, Taylor SR, Khan A, McCluskey P, Lynn WA, Manku K, et al. Factors determining visual outcome in endogenous Candida endophthalmitis. Retina 2012;32:1129-34.  Back to cited text no. 12
Sato T, Kinoshita R, Taguchi M, Sugita S, Kaburaki T, Sakurai Y, et al. Assessment of diagnostic and therapeutic vitrectomy for vitreous opacity associated with uveitis with various etiologies. Medicine (Baltimore) 2018;97:e9491.  Back to cited text no. 13
Negretti GS, Chan W, Pavesio C, Muqit MM. Vitrectomy for endophthalmitis: 5-year study of outcomes and complications. BMJ Open Ophthalmol 2020;5:e000423.  Back to cited text no. 14


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