Aspergillus endophthalmitis in orthotopic liver transplantation

Indian Journal of Medical Sciences, Jun 2009 by Hosseini, Hamid, Saki, Soraya, Saki, Nasrin, Eghtedari, Masoomeh

Introduction

Aspergillus endophthalmitis (AE) is a rare invasive form of aspergillosis and can occur as exogenous and endogenous infection. The former is a complication of ocular penetrating injury or surgery, whereas the latter has been generally reported as associated with intravenous drug abuse, solid organ transplants and cancer. [1],[2],[3]

Our report presents a fulminant course of this infection in an adult after orthotopic liver transplant. Despite treatment, which generally includes pars plana vitrectomy (PPV), intravitreal amphotericin B, systemic amphotericin B and oral antifungal agents, the visual prognosis remains grave, and the risk of mortality is high. [4],[5]

Case Report

A 22-year-old man with allogenic orthotopic liver transplantation due to drug-induced liver failure (sodium valporate) referred to the ophthalmology emergency clinic. The patient complained of decreased visual acuity in his left eye of 3 days' duration about 3 weeks after liver transplantation. He was on immunosuppressive medications (azathioprine and mycophenolate mofetil [MMF]). He did not have any ocular problem before the operation.

Best-corrected visual acuity was 20/20 in right eye; and in the left eye, there was detection of hand-motion only. Intraocular pressure was 12 mm Hg in both eyes. Slit-lamp examination of the left eye revealed mild conjunctival hyperemia, 2 to 3 cells in anterior chamber, clear lens and vitreous inflammation (intense cellularity and whitish debris).

Ophthalmoscopy through the dilated pupil showed moderate vitreous haze with diffuse retinal edema and multifocal large (several disc diameter area) subretinal mass-like lesions. Due to hazy vitreous, the lesions could not be evaluated well, so ocular sonography was requested.

In ocular sonography, posterior segment wall thickening, partial retinal detachment and choroidal detachment were detected The right eye revealed no abnormalities. These findings were suggestive of a unilateral endogenous endophthalmitis, especially fungal endophthalmitis; therefore, systemic workup for infection was done. Intravenous therapy with amphotericin B (conventional) 0.7 mg/kg/day, Imipenem and vancomycin was started according to clinical diagnosis. Pars plana core vitrectomy was performed. Undiluted samples from vitreous and aqueous were used for pathogen identification. An intravitreal injection of amphotericin (50µg/mL), vancomycin (10 mg/mL) and ceftazidime (20 mg/mL) were administered. Topical amphotericin and atropine were started. KOH smear showed fungal hyphae. Samples from anterior chamber and vitreous were sent for aerobic and anaerobic bacterial and fungal cultures.

While aqueous humor yielded no growth, vitreous specimen was positive for Aspergillus. Blood and urine samples were culture negative. Chest x-ray was normal. No systemic findings, such as fever, skin lesions, neurological abnormalities, in favor of invasive aspergillosis were detected. Erythrocyte sedimentation rate was normal. Complete blood count was normal except for thrombocytopenia.

In the first postoperative week, no improvement was observed. So intravenous amphotericin was changed to IV voriconazole (6 mg/kg 2 doses 12 hours apart, followed by maintenance dose of 4 mg/kg every 12 hours), and intravitreal voriconazole (1000 µg/mL) was injected.

In the following week, visual acuity of his left eye did not improve but declined to light perception. Another intravitreal injection of voriconazole was administered 6 days after the first one. Conjunctival congestion and anterior chamber reaction decreased, but the vitreous demonstrated increased opacity. Two weeks later, the left eye became painful and vision decreased to no light perception. A cataract developed in the lens, anterior chamber became shallow, and yellowish dense vitreous opacity was seen behind the lens. Also corneal edema was seen. Ultrasonography showed total retinal detachment. To remove this possible source of continuous infection, the eye was eviscerated and subjected to histopathologic examination. Macroscopically, prominent yellowish exudates occupied vitreous cavity. During operation, no sclera involvement was detected. Histopathologic findings demonstrated granulomatous reaction with severe necrosis in vitreous cavity and multinucleated giant cell. A multitude of dichotomous branching septated fungal hyphae in necrotic area were also detected [Figure 1]. Sphere ball was implanted, and the patient was followed up with full examination of the other eye. No involvement of the other eye was detected after 1 year follow-up.

Discussion

In this report, we describe a patient with drug-induced liver failure who developed endogenous endophthalmitis after liver transplantation.

In the literature, Aspergillus endophthalmitis is described as a fulminant and devastating process. [1],[2],[3] Aspergillus endophthalmitis has been reported following antibiotic administration, surgical procedures; in parenteral drug abusers and in patients with malignancy (lymphoma and leukemia). [1],[2],[3],[4],[7],[8],[9] However, the main risk group comprises of individuals that have received immunosuppressive agents and transplant recipients. [6],[7]