Presumed bilateral endogenous Cryptococcus neoformans endophthalmitis with concomitant Toxoplasma gondii retinochoroiditis

Abstract

Purpose: To report a case of bilateral endogenous Cryptococcus endophthalmitis with Toxoplasma retinochoroiditis.

Observations: A 57-year-old woman with history of renal transplantation developed Cryptococcus neoformans fungemia and meningitis. Reporting bilateral blurry vision, she was found to have associated bilateral endophthalmitis suspicious for endogenous cryptococcal endophthalmitis that was initially responsive to intravitreal voriconazole injections but subsequently worsened despite systemic and intraocular anti-fungal treatments. Given her refractory disease, additional testing was performed, which revealed added infection with Toxoplasma gondii. She underwent bilateral vitrectomy with povidone-iodine infusion and systemic parasiticidal treatment with improvement and stability of her condition.

Conclusions and importance: Immunocompromised hosts are at risk for infection with multiple opportunistic infections that may require broad testing and aggressive medical and surgical therapies.

Keywords: Cryptococcus neoformans; Endogenous endophthalmitis; Immunocompromised; Opportunistic infection; Toxoplasma gondii.

Fig. 1

(A, B): At presentation, bilateral multifocal retinochoroidal lesions were noted in the fundus with associated vitritis and inferior snowballs. There were pre-retinal fibrosis and a cream-colored lesion overlying the macula in the left eye. (C, D): Initial improvement and consolidation of the retinochoroiditis after three weekly intravitreal voriconazole injections, 19 days after presentation. Following multiple intravitreal injections of voriconazole, vitrectomy, and silicone oil placement the right eye recovered significant vision (20/150) (E); however, the left eye (F) did not (LP).

Fig. 2

Optical coherence tomography of the right macula obtained at presentation (A) and two months later (B). Progression of retinitis in the inferotemporal macula with encroachment of the fovea (B) in conjunction with possible inferior retinal detachment prompted the decision to proceed with vitrectomy.