Chronic coccidioidomycosis endophthalmitis without concomitant systemic involvement: a clinicopathological case report

Abstract

Objective: To report the diagnostic, clinical, and histopathologic features of a patient with coccidioidomycosis endophthalmitis without concomitant systemic involvement diagnosed by vitreous biopsy.

Design: Interventional case report.

Participants: One patient.

Intervention: Diagnostic pars plana vitrectomy, systemic and intravitreal antifungal treatment, and enucleation.

Main outcome measures: Diagnostic, clinical, and histopathologic features of chronic coccidioidomycosis endophthalmitis.

Results: A 64-year-old white man from Southern California presented with chronic intraocular inflammation in the right eye that had lasted 18 months. He had been unsuccessfully treated with topical and subtenon steroids. At presentation, best-corrected visual acuity was 20/400 in the right eye and 20/20 in the left eye. Ophthalmoscopy of the right eye revealed significant vitritis and multiple yellowish chorioretinal lesions. Evaluation by an internist showed no underlying inflammatory, infectious, or neoplastic systemic illnesses. A vitreous biopsy followed by histopathologic examination showed the presence of multiple Coccidioides sp. microorganisms. The patient was then treated with intravitreal amphotericin B and oral fluconazole. Best-corrected visual acuity initially improved to 20/80, but inflammation progressed and did not respond to 2 subsequent injections of antifungals, 2 additional pars plana vitrectomies, and oral fluconazole. The eye eventually became blind and painful and was enucleated. Histopathologic examination disclosed intraocular granulomas displaying multiple Coccidioides sp. microorganisms.

Conclusions: Coccidioides sp. endophthalmitis may present with no concomitant systemic involvement. Histopathologic examination of the vitreous is helpful in the diagnosis. A high index of suspicion is important, especially in areas where the incidence of coccidioidomycosis is rising.

Figure 1

Fundus aspect of the right eye at presentation. A. Montage color fundus photograph showing significant vitreous haze and multiple grey-yellowish chorioretinal lesions. Note that inferiorly these lesions are distributed around an area of chorioretinal scarring. B. Montage of late phase fluorescein angiogram frame, showing disc leakage, diffuse venular staining and hypofluorescence of the large lesion inferiorly.

Figure 2

Histopathologic aspects. A. Cell block preparation of undiluted vitreous specimen, showing the presence of lymphocytes. A mature spherule of Coccidioides sp. is seen (hematoxylin-eosin, original magnification ×400). The spherule stains with Gomori methenamine silver (inset, ×400). B. Section of epiretinal membrane specimen obtained during diagnostic vitrectomy, revealing infiltration of lymphocytes and plasma cells. Epithelioid cells are also seen. A mature spherule of Coccidioides sp. full of endospores (arrow) can be identified. (hematoxylin-eosin, original magnification ×400). C. Section of the globe after enucleation, with retinal detachment and disorganization of intraocular contents (hematoxylin-eosin, original magnification ×1). A Coccidioides sp. spherule can be seen within subretinal fluid (inset, top right, Periodic acid Schiff [PAS], original magnification ×400). D. Detail of vitreous cavity, showing a granuloma with multiple PAS positive Coccidioides sp. organisms (PAS, original magnification ×100). Epitheliod cells can be seen (arrows), as well as a PAS positive Coccidioides sp. spherule within a multinucleate giant cell (asterisk) (inset, top left, original magnification ×400).