Sudden vision loss heralding COVID-19-associated aspergillosis. Report of 2 cases

Abstract

Purpose: To describe clinical, radiographic, laboratory and cytopathologic findings in 2 patients who developed vision loss due to endogenous aspergillus endophthalmitis during hospitalization for COVID-19 pneumonia.

Observations: Two unvaccinated sexagenarian male smokers lost vision within one month of contracting COVID-19 pneumonia. Initially, both received high dose steroids, nasal cannula oxygen and remdesivir. Immunomodulators tocilizumab or baricitinib were added during week 2 in case 1 and 2 respectively. Upon presentation after discharge from a post-COVID rehabilitation unit, visual acuities were light perception and hand motion. In both cases, inpatient blood and ocular fluid cultures were negative, serum 1,3-beta-D-glucan was positive, and vitreous cytopathology revealed filamentous fungi and PCR was positive for Aspergillus fumigatus. Large solitary intravitreal fungus balls were debulked in patient 1 and excised in patient 2. Final visual acuities were no light perception and 20/200 respectively. MRI revealed previously unsuspected brain and lung lesions consistent with disseminated aspergillosis in patient 2.

Conclusions: Vision loss due to fungal endophthalmitis may be the first or only sign of systemic aspergillosis associated with COVID-19 pneumonia. Aspergillosis should be suspected in patients who develop vision loss. Diagnosis limited by negative fungal cultures may be confirmed by vitreous cytopathology and PCR. Systemic imaging for disseminated aspergillosis is indicated. Ultimate visual acuity may depend upon surgical approach.

Keywords: COVID-19 pneumonia; Disseminated aspergillosis; Fungal endophthalmitis; Fungus ball; Vitrectomy.

Fig. 1

Clinical and cytopathologic findings of two patients with COVID-19-associated endogenous Aspergillus fumigatus endophthalmitis. A. Hypopyon (arrow) with disproportionately mild conjunctival injection (patient 1). B. Vitritis improved and intravitreal mass (arrow) was visible after treatment with systemic voriconazole during initial hospitalization (patient 1). C. B-scan ultrasound of patient 1 upon presentation demonstrates dense vitritis and large solitary spherical intravitreal mass (arrow). D. Vitritis with posterior vitreous mass (arrow) at presentation in patient 2. E. B-scan ultrasound of patient 2 demonstrates solitary spherical mass over optic disc (arrow) with associated traction detachment. F. One of several rim enhancing lesions (arrow) on brain MRI of patient 2. G. Cell block preparation of vitreous fluid demonstrates filamentous fungal hyphae (arrow) in a background of neutrophils and necrosis (hematoxylin-eosin; ×400). H. Grocott methenamine silver (GMS) stain highlights fungal forms (GMS; ×400). I. Post-operative appearance patient 2 with residual preretinal fibrous material. No change was observed during follow-up.