Retinal involvement secondary to viruses can range from a self-limiting to a sight-threatening disease. Uveitis by Influenza A virus (H1N1) is uncommon. We report a patient who developed acute foveal retinitis following H1N1 infection, which marked an early presentation of an endogenous fungal endophthalmitis.
A 43-year-old male with bilateral pneumonitis and H1N1 (Swine-flu) infection, presented with decreased vision in left eye for five days. HIV was negative. Right eye was normal. Left eye had 3/60 vision with normal anterior segment and a yellowish-white, coin-shaped lesion at the fovea [Fig. 1a, left panel]. Spectral domain optical coherence tomography (SD-OCT) revealed a hyperreflective lesion at fovea involving all retinal layers [Fig. 1a, right panel]. Fluorescein angiography was inconclusive. Considering the recent viral febrile illness and positive H1N1 test, oral corticosteroids were started empirically for sight-threatening viral retinitis.
5 days later, the lesion worsened clinically [Fig. 1b, left panel] and on SD-OCT [Fig. 1b, right panel]. Following a diagnostic pars plana vitrectomy, the lesion regressed as seen clinically [Fig. 1c, left panel] and on SD-OCT [Fig. 1c, right panel]. Fungal smear revealed septate branching hyphae [Fig. 2a], panfungal polymerase chain reaction was positive [Fig. 2b]. BLAST analysis showed Candida albicans amplicon. Following oral antifungal therapy, the lesion was healed at 2 months [Fig. 2c].
Retinal involvement due to H1N1 is rare and responds to systemic corticosteroids. Diagnosis of endogenous candida endophthalmitis is challenging, especially during the first stage of the disease, which is often limited to chorioretinal involvement.
Our case highlights the importance of a high index of suspicion of fungal infection in the setting of an acute retinitis, in an immunocompetent patient with recent history of a viral systemic illness, to differentiate between the two, as the treatment is completely different.
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