An Outbreak of Endogenous Fungal Endophthalmitis Among Intravenous Drug Abusers in New England

Abstract

Importance: Intravenous drug abuse (IVDA) is a known risk factor for endogenous fungal endophthalmitis (EFE), a severe intraocular infection caused by hematogenous seeding of mycotic organisms to the eye. Reporting significant increases in heroin-related deaths since 2014, the New England region is in the midst of an opioid crisis that has led to a substantial increase in patients at risk for this vision-threatening disease.

Objective: To present an update on characteristics, management, and visual outcomes in patients with EFE.

Design, setting, and participants: Medical records review was initiated on July 1, 2016, evaluating all patients with EFE referred to New England Eye Center at Tufts Medical Center, a tertiary care ophthalmology practice distributed throughout Massachusetts, from May 1, 2014, to May 1, 2016. Patients with a history of IVDA and culture-proven or clinical evidence of fungal endophthalmitis were included.

Exposures: Intravenous drug use.

Main outcomes and measures: Patient demographics, comorbidities, presenting symptoms and vision, vitreoretinal findings, treatment regimens, culture data, and final visual acuities.

Results: Ten patients (5 women) with IVDA-related EFE were identified between May 1, 2014, and May 1, 2016-an increase from 3 patients treated from May 2012 to April 2014. The mean (SD) patient age was 34 (11) years (range, 24-60 years). Presenting visual acuities ranged from 20/25 to hand motion. The most common presenting symptoms were floaters (n = 8), reduced vision (n = 6), and pain (n = 5). Initial treatment included systemic antifungals in all patients and intravitreal antifungals in 9 eyes. Five patients required pars plana vitrectomy for worsening vitritis. The most commonly isolated pathogen was Candida albicans in 20% of the patients. Final visual acuity ranged from 20/40 to 20/300.

Conclusions and relevance: The data provided in this report suggest that EFE represents severe end organ damage associated with IVDA and portends poor visual outcomes. Health care professionals must maintain a high suspicion for EFE, as patients are typically ambulatory on presentation without systemic signs of infection.

Figure 1.. Initial Fundus Examination in 3 Intravenous Drug Abusers

A, Single macular chorioretinal lesion with localized overlying vitritis (patient 5). B, Chorioretinal lesion in the superior macula with overlying fluffy vitreous opacities (patient 4). C, String of pearls vitritis (patient 10).

Figure 2.. Fungal Endophthalmitis in an Intravenous Drug Abuser in Her 20s

A, Worsening vitritis 5 days after intravitreal voriconazole. B, Eleven weeks after vitrectomy, there was resolution of vitritis with residual fibrosis and exudates.