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Anterior chamber exudative mass due to Scedosporium apiospermum in an immunocompetent individual

Shankar, Sandeep MS; Biswas, Jyotirmay MS; Gopal, Lingam MS; R, Bagyalakshmi MSMLT; Therese, Lily PhD; Borse, Nishikant J MS

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Indian Journal of Ophthalmology: May–Jun 2007 - Volume 55 - Issue 3 - p 226-227
doi: 10.4103/0301-4738.31949
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Abstract

Scedosporium apiospermum intraocular infection in immunocompetent individual is very rare. Only one case has been reported so far. We report an additional case of S. apiospermum intraocular infection in the form of anterior chamber exudative mass in an immunocompenent individual. The patient was successfully managed with anterior chamber wash, intracameral and intravitreal injection of voriconazole

Case Report

A 61-year-old man presented with sudden diminution of vision in the right eye since two weeks associated with pain, redness and watering. A history of type 2 diabetes mellitus and hypertension well controlled with medication was elicited. He was also a known patient of glaucoma on regular treatment with topical anti-glaucoma medication. There was no history of trauma. On examination the best corrected visual acuity was hand movements close to face in the right eye and 20/20 in the left eye. Intraocular pressures were 20 and 19 mmHg respectively. Slit-lamp examination revealed a yellowish-white exudative mass measuring 10´6 mm in the anterior chamber, adherent to the corneal endothelium in the right eye. There was associated corneal edema, dense anterior chamber reaction and hypopyon. Aqueous flare and cells were both 3+. Severe circumcorneal injection was noted [Fig. 1]. Fundus details were obscured partially due to the corneal edema and anterior chamber reaction, but appeared essentially normal. No abnormality was detected in the left eye. A clinical diagnosis of endogenous endophthalmitis of unknown etiology was made.

Figure 1
Figure 1:
Split-lamp photograph showing anterior chamber exudates before treatment

Anterior chamber tap was done which on direct smear revealed septate fungi by KOH- calcofluor stain. Oral ketaconazole 200 mg twice daily and topical natamycin half hourly were prescribed (Natamet 5%, Sun Pharmaceuticals, Gujarat, India). On day 2 no improvement in the patient's condition was noted. An intravitreal injection of amphotericin B 5 mg was administered. On day 3 there was no resolution of anterior chamber exudate. Treatment was supplemented with amphotericin eye drops half hourly. Amphotericin vial for intravenous injection contains 50 mg of amphotericin B. With added salts it weighs 100 mg/vial. We take 15 mg of amphotericin B powder and dissolve it in 5 ml of distilled water to prepare 0.15% amphotericin B eye drops. This is done in our microbiology department with sterile precautions by a technician.

Test for HIV was found to be negative. Culture of the aqueous aspirate sample in Sabouraud's dextrose agar media showed growth of Scedosporium apiospermum [Fig. 2]. The patient was subjected to anterior chamber wash and intracameral injection of voriconazole 50 mg. Topical administration of voriconazole drops prepared from the parenteral preparation was also started half hourly. Marked resolution of the anterior chamber exudate was noted on subsequent days. However, on day 11, during a routine follow-up visit, presence of vitreous exudate was noted. The exudate was at the site of previous intravitreal injection. Intravitreal injection of voriconazole was then administered. Since then, the patient has made remarkable progress showing complete resolution of the anterior chamber and vitreous exudates [Fig. 3].

Figure 2
Figure 2:
Scedosporium apiospermum - colony morphology on Lactophenol Cotton blue mount (LPCB, 40x)
Figure 3
Figure 3:
Resolved anterior chamber exudates after treatment

Voriconazole (VFEND, Pfizer Inc., New York) is available as a white lyophilized powder containing 200 mg of voriconazole presented in a 30 ml clear glass vial. The powder was reconstituted with 19 ml of distilled water to obtain 20 ml of clear concentrate containing 10 mg/ml of voriconazole.

Voriconazole injected as as a single injection in a concentration of 50 mg in 0.1 ml solution either intracamerally or intravitreally. Topical voriconazole was prepared to a concentration of 1%.

Discussion

Ocular infection due to S. apiospermum is an extremely rare entity1 and when it occurs, it usually affects the cornea. Traumatic implantation is the usual mode of infection. Endogenous endophthalmitis in an immunocompetent individual due to this organism has been reported only once before.2 There is one more report of endophthalmitis due to S. apiospermum in an immunocompromized patient who was receiving immunosuppressive agents for renal transplant (mycophenolate, tacrolimus and corticosteroid).3 There is also a report of chorioretinitis due to S. apiospermum in an immunocompetent individual.4S. apiospermumis a filamentous fungus found in soil, polluted water and decaying vegetable matter. The sexual form of the fungus is called Pseudallescheria boydii.

The organism is relatively resistant to amphotericin B in vitro. Natamycin is the first-line drug against filamentous fungi but it penetrates the cornea poorly. A few studies in recent times have emphasized the efficacy of the new drug voriconazole against various fungal species.35 It has been seen in a recent study on a rodent animal model that the intravitreal use of this drug does not cause any electroretinographic or histopathological changes in the eye.6 The efficacy of orally administered voriconazole in humans has also been recently determined.7 Voriconazole was seen to achieve therapeutic levels in the aqueous and vitreous. It was seen to have a broad spectrum of coverage, low MIC levels, good tolerability and excellent bio-availability. Some reports have testified the good response to this drug in cases of keratomycosis.89

Our case was unique due to the rarity of presentation in an immunocompetent individual with no history of ocular trauma of vegetative origin or otherwise. The site of the initial ocular involvement was also unusual. This report also highlights that aggressive medical and surgical management required to salvage eyes affected by fungal endophthalmitis. Early detection and energetic treatment are critical. Our report also indicates that voriconazole is a safe, effective and promising anti-fungal antibiotic for intraocular fungal infection

Financial Support:

Vision Research Foundation, Chennai, India Proprietary Interest: The authors have no financial interest in any of the materials used in the study.

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Keywords:

Endogenous endophthalmitis; immunocompetent; voriconazole

© 2007 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow