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 Table of Contents    
CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 379-381  

Cladosporium spp. endogenous endophthalmitis simulating the classic “headlight-in-the-fog” appearance of active toxoplasmosis


1 Department of Ophthalmology and Visual Science, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
2 Department of Ophthalmology, Hospital Selayang, Lebuhraya Kepong-Selayang, Batu Caves, Selangor, Malaysia

Date of Submission08-Dec-2020
Date of Decision29-Jul-2021
Date of Acceptance25-Sep-2021
Date of Web Publication02-Nov-2022

Correspondence Address:
Julieana Muhammed
Department of Ophthalmology and Visual Science, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kota Bharu 16150, Kelantan
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.ojo_459_20

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   Abstract 


Endogenous fungal endophthalmitis caused by an unusual fungus poses both diagnostic and therapeutic challenges. We report a case of endogenous endophthalmitis caused by a rare mold, namely Cladosporium spp., which presented with a foveal abscess. A 52-year-old male patient who was diagnosed with rectal carcinoma presented with pain, redness, and a loss of vision in the right eye. He had been experiencing the symptoms for 1 week. The patient had undergone gastrointestinal surgery 2 weeks before experiencing the eye complaint. His best-corrected visual acuity was hand movements. Fundus examination revealed a foveal abscess of around a half-disc diameter in size that simulated retinochoroiditis with vitritis. Optical coherence tomography of the macula revealed a hyperreflective lesion in the fovea, which breached the full thickness of the fovea and extended into the preretinal space. Ocular toxoplasmosis was considered. On that basis, oral trimethoprim/sulfamethoxazole was given for 1 week, although the patient's condition worsened. A vitreous tap and an intravitreal combination of vancomycin, ceftazidime, and amphotericin B were administered twice but did not improve the patient's condition. Pars plana vitrectomy was performed and the vitreous biopsy results revealed the presence of Cladosporium spp. Intravitreal voriconazole was given three times and the foveal abscess resolved into a scar. Endophthalmitis caused by Cladosporium spp. is uncommon and published case reports are extremely limited. The present case may provide insight into the variable presentation of fungal endophthalmitis and, therefore, assist with the early diagnosis and appropriate management of the condition.

Keywords: Cladosporium endophthalmitis, Cladosporium spp., endogenous endophthalmitis, fungal endophthalmitis


How to cite this article:
Hamid AA, Lay Suan AL, Hashim H, Kamarudin Z, Muhammed J. Cladosporium spp. endogenous endophthalmitis simulating the classic “headlight-in-the-fog” appearance of active toxoplasmosis. Oman J Ophthalmol 2022;15:379-81

How to cite this URL:
Hamid AA, Lay Suan AL, Hashim H, Kamarudin Z, Muhammed J. Cladosporium spp. endogenous endophthalmitis simulating the classic “headlight-in-the-fog” appearance of active toxoplasmosis. Oman J Ophthalmol [serial online] 2022 [cited 2022 Dec 4];15:379-81. Available from: https://www.ojoonline.org/text.asp?2022/15/3/379/360420




   Introduction Top


Endogenous fungal endophthalmitis is a rare condition, accounting for only approximately 5%–15% of all cases of endophthalmitis.[1] Compromised immunity is an important risk factor for endogenous fungal endophthalmitis. Other significant risk factors include the introduction of foci of infection into the bloodstream due to gastrointestinal surgery, intravenous hyperalimentation, the use of indwelling intravenous catheters, or intravenous drug abuse.[2] Candida albicans and Aspergillus spp. account for most cases of endogenous fungal endophthalmitis.[2]

The clinical signs and symptoms of endogenous fungal endophthalmitis are highly variable and may overlap with infectious, noninfectious, and malignant causes of endophthalmitis. Fungal endophthalmitis due to Candida typically presents as chorioretinitis accompanied by multiple and bilateral lesions in the majority of cases.[3] Larger and more severe chorioretinal lesions involving the posterior pole are seen in the case of Aspergillus endophthalmitis.[4]

Endogenous fungal endophthalmitis caused by Cladosporium spp. is a rare condition. Indeed, there have been only an extremely limited number of published reports on Cladosporium spp. endophthalmitis with variable clinical features.[2],[5] We report a rare case of Cladosporium spp. endogenous endophthalmitis, which simulated the classic “headlight-in-the-fog” appearance of active toxoplasmosis. The absence of an adjacent chorioretinal scar, compromised immunity, and a history of gastrointestinal surgery are all important factors in the early detection of endogenous fungal endophthalmitis.


   Case Report Top


A 52-year-old male patient presented with pain, redness, and generalized blurring of the vision in the right eye. He had been experiencing those symptoms for 1 week. The patient's surgical history revealed that he had been diagnosed with locally advanced rectal carcinoma. Moreover, he had undergone laparoscopic abdominoperineal resection and received adjunctive chemoradiotherapy 1 month earlier. The patient's general condition after surgery was good. However, he had developed an acute fever on the 1st postoperative day. The source of the infection had not been identified. The patient was discharged 4 days after surgery. Two weeks later, he presented at our clinic due to the above-mentioned eye problems.

The patient's best-corrected visual acuity upon presentation was hand motion in the right eye and 6/9 in the left eye. There was no relative afferent pupillary defect. Anterior segment examination of the right eye revealed injected conjunctiva and a clear cornea with anterior chamber cells of 3+. Fundus examination showed a white foveal lesion of around a half-disc diameter in size with overlying generalized vitritis that mimicked the typical “headlight-in-the-fog” appearance of active toxoplasmosis [Figure 1]a. The optic disc was pink, and the peripheral retina and vessels were normal. Optical coherence tomography (OCT) revealed a hyperreflective lesion in the fovea that had broken through the retina into the vitreous [Figure 1]b. Thus, a diagnosis of ocular toxoplasmosis was considered. While waiting for the serology results, oral trimethoprim/sulfamethoxazole was administered and the patient was treated in the outpatient department. After 1 week, his condition had worsened so that there was more severe generalized vitritis and the fundus could not be visualized in detail. B-scan ultrasonography revealed significant vitritis with loculation. The serum toxoplasma results came back positive for immunoglobulin G and negative for immunoglobulin M. Further assessment of the patient's medical record revealed that his blood culture had tested positive for C. albicans, which was collected 3 weeks previously during the patient's febrile episode following surgery.
Figure 1: A white foveal lesion of around a half-disc diameter in size with overlying generalized vitritis that mimicked the typical “headlight-in-the-fog” appearance of active toxoplasmosis (a). Optical coherence tomography revealed a hyperreflective lesion in the fovea that had breached through the retina into the vitreous (b)

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The patient was diagnosed with endogenous fungal endophthalmitis and admitted. Intravenous ciprofloxacin and fluconazole were started. An immediate vitreous tap and an intravitreal combination of vancomycin, ceftazidime, and amphotericin B were given. However, the patient's vitreous sample revealed no growth of any organism. Further investigations were performed to identify any foci of infection. The echocardiogram revealed no vegetation in the heart, while the abdominal ultrasonography findings were normal.

The patient's condition did not improve after 48 h. Thus, a second course of intravitreal vancomycin, ceftazidime, and amphotericin B was administered. As further eye assessment did not reveal any signs of improvement, pars plana vitrectomy was performed, and a vitreous biopsy was sent for microscopic and culture analysis and cytologic evaluation. Another course of intravitreal vancomycin, ceftazidime, and amphotericin B was administered. Intraoperatively, the fundus showed dense vitritis inferiorly accompanied by a foveal abscess and peripheral retinal detachment from 4 to 5 o'clock. Silicone oil tamponade was also performed.

On the 1st postoperative day, the foveal lesion increased to around a one-disc diameter in size, which was indicative of a poor response to the intravitreal vancomycin, ceftazidime, and amphotericin B previously administered. Intravitreal voriconazole (100 μg/0.1 mL) was considered and injected. Oral fluconazole (200 mg daily) was also initiated. The vitreous biopsy results came back on the 2nd postoperative day and revealed that the patient was positive for Cladosporium spp. This was evaluated using the lactophenol cotton blue staining technique, which stains the chitin found in the fungal cell walls. Cytological evaluation revealed the absence of any malignant cells. Second and third courses of intravitreal voriconazole at the same dose were given at an interval of 48 h based on improvements observed in the form of a smaller foveal lesion. The patient was discharged with continuation of daily oral fluconazole for 3 weeks. At the 1-month follow-up appointment, the fundus showed a foveal scar [Figure 2]a, while the OCT macula revealed a foveal scar with an epiretinal membrane [Figure 2]b. The patient's best-corrected visual acuity was counting fingers from a distance of three foot.
Figure 2: Fundus showed a foveal scar (a). The optical coherence tomography of the macula revealed foveal scar with epiretinal membrane (b)

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   Discussion Top


Endogenous fungal endophthalmitis most commonly occurs in immunocompromised patients. Although the pathogenesis of the condition can involve hematogenous spread to the eye, the incidence rate of endophthalmitis is only 1.6%.[5] The ocular presentation may vary in rare cases, rendering diagnosis challenging. In a large series of patients with ocular candidiasis, chorioretinitis was the most common finding.[5] Typically, there are multiple lesions and involvement in both eyes.[3] By contrast, our patient presented with an foveal abscess accompanied by vitritis, which was mistakenly interpreted as the classic “headlight-in-the-fog” appearance of active toxoplasmosis. The clinical sign seen in our case was also observed in a case reported by Singh et al. (2021). However, in that case, there were multiple, peripherally located lesions.[5]

A search of the literature available through databases such as Medline and PubMed using the keywords “Cladosporium endophthalmitis” and “Cladosporium” was performed. The results revealed that there have been only a few reports of Cladosporium spp. causing keratitis, keratopathy, and endophthalmitis.[2],[5],[6],[7] In a large-scale review of cases of endophthalmitis, only one case was associated with Cladosporium spp. endophthalmitis, which was related to postkeratoplasty due to a ruptured cornea ulcer.[2]

Endogenous fungal endophthalmitis caused by a rare organism poses therapeutic challenges. Early vitrectomy should be considered if there is no response to the initial treatment or if the condition is deemed severe and sight threatening.[8] The most commonly used initial antifungal treatments include amphotericin B and triazoles. However, voriconazole should be considered in cases of resistance.[9] Moreover, voriconazole is the treatment of choice for Cladosporium spp.[10] Although amphotericin B and fluconazole are also recommended in this regard, in the present case, the patient exhibited a better response to intravitreal voriconazole combined with pars plana vitrectomy.


   Conclusion Top


In conclusion, Cladosporium spp. is a rare cause of endogenous fungal endophthalmitis and may mimic the appearance of toxoplasma retinochoroiditis. Vitreous biopsy may aid in the identification of the condition in the absence of a positive organism test by means of routine intravitreal tapping. Intravitreal voriconazole combined with pars plana vitrectomy shows a promising response in relation to Cladosporium spp. endophthalmitis.

Informed consent to publish was obtained from the patient and ethical approval for the report was granted by the local ethics committee (NIH.800-4/4/1 Jld. 90 (23)).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Vaziri K, Schwartz SG, Kishor K, Flynn HW Jr. Endophthalmitis: State of the art. Clin Ophthalmol 2015;9:95-108.  Back to cited text no. 1
    
2.
Dimacali VG, Lim Bon Siong R. Infectious endophthalmitis at a Philippine tertiary hospital: A ten-year retrospective study. J Ophthalmic Inflamm Infect 2020;10:19.  Back to cited text no. 2
    
3.
Bross J, Talbot GH, Maislin G, Hurwitz S, Strom BL. Risk factors for nosocomial candidemia: A case-control study in adults without leukemia. Am J Med 1989;87:614-20.  Back to cited text no. 3
    
4.
Rao NA, Hidayat A. A comparative clinicopathologic study of endogenous mycotic endophthalmitis: Variations in clinical and histopathologic changes in candidiasis compared to aspergillosis. Trans Am Ophthalmol Soc 2000;98:183-93.  Back to cited text no. 4
    
5.
Singh P, Madhuravasal Krishnan J, Kumar A, Roy R, Biswas J. Cladosporium endogenous endophthalmitis mimicking toxoplasma retinochoroiditis. Ocul Immunol Inflamm 2021;29:607-8.  Back to cited text no. 5
    
6.
Stock RA, Bonamigo EL, Cadore E, Oechsler RA. Infectious crystalline keratopathy caused by Cladosporium sp. after penetrating keratoplasty: A case report. Int Med Case Rep J 2016;9:267-71.  Back to cited text no. 6
    
7.
Cheng SC, Lin YY, Kuo CN, Lai LJ. Cladosporium keratitis-A case report and literature review. BMC Ophthalmol 2015;15:106.  Back to cited text no. 7
    
8.
Behera UC, Budhwani M, Das T, Basu S, Padhi TR, Barik MR, et al. Role of early vitrectomy in the treatment of fungal endophthalmitis. Retina 2018;38:1385-92.  Back to cited text no. 8
    
9.
Sen P, Gopal L, Sen PR. Intravitreal voriconazole for drug-resistant fungal endophthalmitis: Case series. Retina 2006;26:935-9.  Back to cited text no. 9
    
10.
Espinel-Ingroff A, Boyle K, Sheehan DJ. In vitro antifungal activities of voriconazole and reference agents as determined by NCCLS methods: Review of the literature. Mycopathologia 2001;150:101-15.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2]



 

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