Posterior hypopyon in fungal endogenous endophthalmitis secondary to presumably contaminated dextrose infusion

Abstract

Purpose: To describe the presentation, clinical course and management of a patient with posterior hypopyon secondary to atypical (fungal) endogenous endophthalmitis.

Observations: A 55-year-old Asian Indian female presented with decreased vision in the left eye (OS). The best-corrected visual acuity was 20/20 in the right eye (OD) and counting fingers (CF) in the left eye (OS) at the time of initial presentation. Slit-lamp examination revealed 1+ cells and 1+ flare in the anterior chamber of OS. Clinical examination and imaging assessment with fundus photography revealed vitritis, a posterior hypopyon and retinal exudates. The patient had an episode of fever one month before presentation for which an intravenous dextrose infusion was administered. After carefully evaluating the patient, ocular images, detailed history and necessary laboratory tests, a working diagnosis of endogenous endophthalmitis was reached. Empirical treatment with topical and systemic antibiotics, and topical cycloplegics and steroids was initiated. Therapeutic and diagnostic pars plana vitrectomy (PPV) was subsequently performed; microbiology and cytology analyses revealed evidence of fungal elements. Therefore, systemic anti-fungal treatment was initiated; the patient demonstrated significant clinical improvement with good visual outcome.

Conclusion and importance: Posterior hypopyon in endophthalmitis is a rarely observed entity and is typically obscured due to dense vitritis. Such clinical manifestation may suggest a possible infectious etiology as described in this case.

Keywords: Aspergillus; Contaminated infusions; Cytology; Dextrose; Endogenous endophthalmitis; Fungal; Immunocompetent; Posterior hypopyon.

Fig. 1

Fundus photograph of the left eye showing significant vitritis, posterior hypopyon (blue arrow) and superficial retinal exudates.

Fig. 2

Cytology of vitreous samples using H&E stain (A) showing ribbon-like, septate fungal (Aspergillus) hyphae. Similar findings are seen on Giemsa Stain (B).Branching hyphae at acute angles (marked by red arrow) with scattered inflammatory cells are seen on Methylene Blue stain (C) suggestive of Aspergillus sp. Frequent septae are seen more prominently (marked by red arrows) on Lactophenol Cotton Blue staining (D). Oral Itraconazole 200 mg twice daily was started and continued for six weeks with monitoring of liver function tests. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 3

Fluorescein angiography of the left eye, conducted on third post-operative day. Early arterio-venous phase (A) showing choroidal hypofluorescence which evolves into stippled hyperfluorescence (B) during laminar flow; further increasing in intensity in (C). Recirculation phase (D) shows disc staining and persistent choroidal hyperfluorescence of the lesion. These features on FA are suggestive of choroiditis.

Fig. 4

Fundus photos showing significant clinical improvement with clear media on post-operative day 1 (A) and visual acuity of CF at 1 meter, RPE atrophy (blue arrow) is visible at 6 weeks (B) and pigmentary changes are visible (yellow arrow) at 18 months (C), with best-corrected visual acuity of 20/60. Media haze (C) is attributable to the development of posterior sub-capsular cataract.