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Panophthalmitis due to Aspergillus in an acquired immunodeficiency syndrome patient

Clinicopathological study of a case

Biswas, Jyotirmay MS; Singh, Chekitaan DNB; Mukherjee, Bipasha MS; Rama Kumar, G V N MD

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Indian Journal of Ophthalmology: May–Jun 2007 - Volume 55 - Issue 3 - p 239-240
doi: 10.4103/0301-4738.31957
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Dear Editor,

Fungal panophthalmitis in acquired immunodeficiency syndrome (AIDS) patients is extremely rare.1 There is no report of panophthalmitis due to Aspergillus (Medline search). We report a case of Aspergillus panophthalmitis in a 52-year-old man with human immunodeficiency virus (HIV) infection. The eviscerated tissue on histopathological examination showed Aspergillus.

A 52-year-old male presented to us with complaints of sudden loss of vision and pain in the left eye for 10 days following fever. There was no previous history of eye surgery or trauma. There was no history of decreased vision before this episode of sudden loss of vision. The patient gave history of multiple unprotected sexual exposures to commercial sex workers. He had been diagnosed with HIV infection one month back and was on anti-tubercular therapy for tubercular meningitis diagnosed on the basis of cerebrospinal fluid examination. He was not on any retroviral therapy. He had a bedsore over the sacral region. There was no history of any other systemic illness. On examination, visual acuity was 20/60, N/6 in the right eye and absence of light perception in the left eye. Ocular movements were full but painful in the left eye. Slit-lamp biomicroscopy revealed pseudophakia with posterior capsule opacification in the right eye. Left eye showed mild lid edema, marked conjunctival congestion and chemosis, opaque cornea with exudates and a central corneal full thickness defect with iris prolapse [Fig. 1]. A clinical diagnosis of panophthalmitis in the left eye was made for which the patient was advised evisceration. Routine laboratory investigations revealed normal total and differential white, blood cell count. Erythrocyte sedimentation rate was 95 mm in the first hour. Platelet counts were 5,58,000/mm3. Urine examination showed few pus and epithelial cells. Anti-HIV 1 antibody was detected by rapid immuno-concentration test and tridot methods from the patient's blood. Tests for Treponema pallidum and hepatitis group of viruses were negative. The patient underwent evisceration. Histopathological examination of the eviscerated tissues revealed dense infiltration by polymorphonuclear leukocytes. There was disorganization of the uveal tissue. Special stains for fungus (Gomori Methanamine Silver) showed multiple septate hyphae with 45o branching, typical of Aspergillus [Fig. 2]. Special stains for bacteria and acid-fast bacilli were found to be negative. The patient was seen by an internist who found no evidence of systemic Aspergillus infection. There was no evidence of sinus or pulmonary disease. The patient was referred to an AIDS care center for evaluation and management of any associated systemic Aspergillus infection and antiretroviral therapy.

Figure 1
Figure 1:
Slit-lamp photograph showing lid edema, conjunctival congestion and chemosis, infiltration and opacification of the cornea, central corneal defect and iris prolapse
Figure 2
Figure 2:
Photomicrograph showing multiple, septate fungi with 45o branching (Gomori Methanamine Silver stain, x200)

Aspergillus species are ubiquitous saprophytic moulds, commonly growing in soil, stored hay and decaying vegetation. Endogenous Aspergillus endophthalmitis is a rare but devastating infection usually associated with disseminated Aspergillosis or with intravenous drug abuse.234 Although Aspergillosis has been documented in patients with AIDS there are no reports of cases of Aspergillus panophthalmitis (Medline search). In a study by Zabsonre et al.,1 it was found that contrary to seronegative patients, panophthalmitis in HIV-infected patients occurred spontaneously without any apparent exogenous cause. In our case, the mode of presentation of sudden onset of visual loss without any history of trauma, surgery or corneal ulceration is suggestive of endogenous infection and is similar with the findings of Zabsonre et al.1 Since the patient was HIV seropositive, the possibility of opportunistic pathogens like fungus was strongly suspected. Special staining of the eviscerated specimen showed Aspergillus fungus. Our case indicates that panophthalmitis due to Aspergillus can occur in an AIDS patient without any apparent history of trauma and can have a fulminant course resulting in loss of vision and structural integrity of the eye.

1. Ahnoux-Zabsonre A, Keita C, Safede K. Panophthalmitis and results of HIV tests. Experience at the Cocody University Hospital Center in Abidjan, Ivory Coast J Fr Ophtalmol. 1998;21:283–6
2. Weishaar PD, Flynn HW Jr, Murray TG, Davis JL, Barr CC, Gross JG, et al Endogenous Aspergillus endophthalmitis: Clinical features and treatment outcomes Ophthalmology. 1998;105:57–65
3. Paula JS, Bryk A Jr, Lauretti Filho A, Romao E. Secondary glaucoma associated with bilateral Aspergillus niger endophthalmitis in an HIV-positive patient: Case report Arq Bras Oftalmol. 2006;69:395–7
4. Perri P, Campa, Incorvaia C, Parmeggiani F, Lamberti G, Costagliola C, et al Endogenous Aspergillus versicolor endophthalmitis in an immuno-competent HIV-positive patient Mycopathologia. 2005;160:259–61
© 2007 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow