Purpose:
To provide a case report of chorioretinitis in a premature neonate with Candida osteomyelitis, leading to the discovery of a fungal endocarditis.
Methods:
Case report of a 28–week gestational age premature girl (1055 grams) born to a 27–year–old woman with an unremarkable prenatal history.
Results:
At 20 days of life, the baby was diagnosed with necrotizing enterocolitis and multifocal osteomyelitis and was treated with hyperalimentation, vancomycin, ceftazidime and gentamycin using a peripherally inserted central catheter (PICC line). MRI showed effusions of the left hip, right shoulder and knee. Arthrocentesis and culture of the knee was positive for Candida albicans, sensitive to fluconazole. Intravenous fluconazole was started and the osteomyelitis improved on serial radiography. Indirect ophthalmoscopy, after 20 days of treatment with fluconazole was remarkable for Stage I Zone III ROP, OU. Repeat indirect ophthalmoscopy and B–scan ultrasonography performed 7 days later revealed stable ROP with a new chorioretinal lesion of the left macula, measuring 0.75 disc diameters and extending 2–mm into the vitreous (Fig). Systemic work–up including multiple blood, urine and CSF cultures were negative. Transthoracic echocardiography demonstrated a large vegetation in the left atrium (Fig). Fluconazole was discontinued and intravenous liposomal amphotericin B was given. The macular lesion decreased in size over the ensuing four weeks (Fig).
Conclusions:
A chorioretinal lesion, in combination with candida infection elsewhere should prompt the ophthalmologist to obtain echocardiography to rule out fungal endocarditis (FE), even in the face of negative blood cultures. FE has a mortality rate of 75 to 90%, often due to delay in making the diagnosis. Blood cultures can be negative in up to 33% of these cases. Lastly, there is little known regarding the efficacy of liposomal amphotericin B against candida chorioretinitis, which in our case was responsive.
Keywords: chorioretinitis • fungal disease • antibiotics/antifungals/antiparasitics