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O. M. Mansuri, D. G. Dodwell; First Survivor of Disseminated Scedosporium Apiospermum Endogenous Endophthalmitis. Invest. Ophthalmol. Vis. Sci. 2007;48(13):686.
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To report on the first survivor of disseminated Scedosporium apiospermum endogenous endophthalmitis.
A 57 year old woman, immunosuppressed with prednisone, mycophenolate, and cyclophosphamide for two renal transplants, was admitted for atypical pneumonia and headaches. Bronchoalveolar lavage (BAL) was culture positive for Nocardia species. She reported a sudden, painless loss of vision in her left eye (OS). On examination, visual acuity (VA) was hand motion (HM) OS with 3+ cell and flare and hypopyon in the anterior chamber. Ultrasonography revealed vitreous debris without evidence of retinal detachment. Evaluation of the right eye revealed a VA of 20/63 and was otherwise unremarkable. Pars plana vitrectomy (PPVx) was performed with a pure vitreous specimen sent for cultures and Gram stain. PPVx revealed a localized area of active retinitis in the superotemporal quadrant, anterior to the equator. Initial treatment included intravitreal injection of dexamethasone (0.4mg), ceftazidime (2.25mg), and vancomycin (1.0mg). BAL was positive for S. apiospermum, and she was discharged on oral voriconazole (400mg daily) following an initial intravenous dose. Vitreous culture also returned positive for S. apiospermum eight days after her initial ocular complaint. She was treated with intravitreal voriconazole (250µg). She was hospitalized two more times for complaints of weakness and fatigue; intravenous medication was changed from voriconazole to micafungin (150µg daily). Her visual acuity varied between HM and no light perception (NLP). Four months following her initial symptoms, she underwent a repeat PPVx and lensectomy of her left eye. Severe pre-retinal fibrosis with multiple layers of thin, avascular tissue without active inflammation was observed. Post-operative visual acuity was NLP. Right eye remained quiet throughout. Serial brain MRIs revealed a slow growing temporal lobe abscess, biopsy positive for S. apiospermum, which improved after changing from voriconazole to micafungin.
Our patient survived over seven months following her diagnosis of disseminated S. apiospermum endogenous endophthalmitis, more than tripling the survival of previous reports. Her clinical condition and MRI lesions improved after changing from voriconazole to micafungin. We considered administering intravitreal micafungin after administering intravitreal voriconazole, and recommend the evaluation of intravitreal micafungin for fungal endophthalmitis.
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