Aspergillus fumigatus scleritis associated with monoclonal gammopathy of undetermined significance

Abstract

A 68-year-old woman presented with pain in her left eye. Necrosis with calcium plaques was observed on the medial part of the sclera. Aspergillus fumigatus was isolated from the culture of the necrotic area. On systemic work-up including serum and urine electrophoresis studies, the serum monoclonal protein of immunoglobulin G was detected. The patient was diagnosed with monoclonal gammopathy of undetermined significance and fungal scleritis. Despite intensive treatment with topical and oral antifungal agents, scleral inflammation and ulceration progressed, and scleral perforation and endophthalmitis developed. Debridement, antifungal irrigation, and tectonic scleral grafting were performed. The patient underwent a combined pars plana vitrectomy with an intravitreal injection of an antifungal agent. However, scleral and intraocular inflammation progressed, and the eye was enucleated. Aspergillus fumigatus was isolated from the cultures of the eviscerated materials. Giemsa staining of the excised sclera showed numerous fungal hyphae.

Keywords: Aspergillus fumigatus; Monoclonal gammopathy of undetermined significance; Scleritis.

Fig. 1

Anterior segment photography and ultrasonography of the left eye. (A) At presentation, scleral necrosis and calcium plaque deposition were observed, with engorged vessels in the surrounding area. (B,C) Despite intensive medical and surgical treatments, scleral melting lead to perforation and progressed inferiorly into the previous scleral graft site (arrows). (D) Scleritis progressed to endophthalmitis. Vitreal inflammation was found on the ultrasonography.

Fig. 2

Giemsa staining of the enucleated eye. Numerous fungal hyphae consistent with Aspergillus were observed in the excised sclera (arrows) (×400).