Candida dubliniensis endophthalmitis: five cases over 15 years

The Effectiveness and Safety of Intravitreal Injections of Voriconazole in the Treatment of Fungal Endophthalmitis: A Systematic Review

Background: Fungus endophthalmitis is a rare and serious infection that is treated with systemic and topical antifungal drugs. There is no clear consensus on the treatment of fungal endophthalmitis with intravitreal injections (IVIs) of voriconazole. This systematic review aims to summarize the literature on IVIs of voriconazole for fungal endophthalmitis. Methods: We conducted a systematic review of the literature to determine the effectiveness and safety of IVIs of voriconazole in the treatment of fungal endophthalmitis. We searched databases such as PubMed and Embase using the following search terms "Endophthalmitis" AND "Intravitreal Injections" AND "Voriconazole" with date limits of January 1, 1900, to December 31, 2022. We included all reports on humans, which described clinical outcomes of IVIs of voriconazole in the treatment of fungal endophthalmitis, including randomized controlled trials (RCTs) and case series. A descriptive synthesis of the data was conducted with a pooling of data for interventions. Results: One RCT and 21 retrospective studies were analyzed in this review. In these reports, a wide range of heterogeneous treatment regimens was used, including IVI in combination with other drugs, systemic therapy in combination with other agents, and surgery. Combined with other treatments, intravitreal voriconazole results in a favorable anatomical and clinical cure that was well tolerated. Conclusions: Reports on IVIs of voriconazole for fungal endophthalmitis demonstrate a heterogeneous approach to treatment. Of these, IVIs of voriconazole in anatomical and clinical outcomes appeared to be highly effective, although more data on its safety are needed.

Molecular characterization of fungal endophthalmitis and keratitis caused by yeasts

Candida species are the most common causes of sight-threatening fungal ocular infections in temperate regions of the world. Despite their relevance, little is known about the emergence of novel species and the molecular epidemiology of these infections. Here, we molecularly characterized 38 yeast isolates collected from patients diagnosed with endophthalmitis or keratitis at Massachusetts Eye and Ear from 2014 to 2021. Sequencing of the ITS1-5.8S-/ITS2 regions demonstrated that this population of yeasts was dominated by Candida spp. (37 out of 38; 97%), with 58% of the cases caused by C. albicans (n = 22) and the remaining by emerging non-albicans species, predominantly by C. parapsilosis (n = 8) and C. dubliniensis (n = 6). One isolate each was identified as C. tropicalis and Clavispora lusitaniae. Interestingly, all C. dubliniensis were isolated from endophthalmitis and most C. parapsilosis from keratitis. Multilocus sequence typing analysis of C. albicans showed a prevalence of CC-1 isolates that has DST69 as the putative founder, with 64% of them belonging to this clonal complex (CC). Isolates grouped within this cluster were more predominant in endophthalmitis (10 out of 14; 71%). One C. albicans CC-1 isolate was multi-azole resistant. In conclusion, we observed that nearly half of the ocular infections caused by yeasts are associated with C. albicans, with evidence for the emergence of non-albicans species that are differentially enriched in distinct ocular niches. Candida albicans isolates clustered within the predominant CC-1 group were particularly more common in endophthalmitis, demonstrating a potential pattern of ocular disease enrichment within this clade.

A Case of Bilateral Endogenous Candida dubliniensis Endophthalmitis Treated with Aggressive Local and Systemic Therapy

Candida dubliniensis is an emerging pathogen implicated in a variety of infections in immunocompromised hosts. A 79-year-old male with autoimmune pancytopenia on chronic oral steroid therapy was admitted for suspected sepsis and started on empirical antibiotics and micafungin. He developed floaters and decreased vision while on this regimen and was diagnosed with bilateral candida endophthalmitis. Blood cultures grew C. dubliniensis.Intravenous therapy was switched to voriconazole and amphotericin B. He also received aggressive intravitreal antifungal therapy consisting of 100 μg/0.1 mL voriconazole (4 OD, 3 OS) and 5 μg/0.1 mL amphotericin B (3 OD, 1 OS) over 2 weeks that resulted in local control of infection. The right eye developed a retinal detachment 1 month after initial presentation that was repaired by 25-gauge pars plana vitrectomy, scleral buckle, laser and silicone oil. At the 15-month follow-up exam, subsequent to silicone oil removal, membrane peel and cataract surgery, OD visual acuity had improved to 20/80. OS was phakic and 20/25. Aggressive intravitreal antifungal therapy combined with intravenous therapy may control endophthalmitis and avoid the risks associated with pars plana vitrectomy during acute infection.

Combined Candida dubliniensis and Candida albicans Keratitis following a Chemical Injury

Candida dubliniensis is an uncommon source of ocular infections and has only been reported in a single previous case of keratitis. This report documents the course of a combined Candida dubliniensis and Candida albicans keratitis following a chemical injury. Antifungal sensitivities of the two different Candida species are also demonstrated.

Candida dubliniensis: A novel cause of fungal keratitis

A 45-year-old female with history of contact lens wear presented with a persistent corneal ulcer that was unresponsive to topical moxifloxacin. The patient's exam was concerning for fungal keratitis. Cultures were obtained, and the patient was started on fortified amphotericin B drops and oral voriconazole. The cultures identified Candida dubliniensis as the causative organism. The patient's exam worsened despite treatment, and the decision was made for surgery. At the time of surgery, her cornea was found to have unexpectedly perforated. She underwent cryotherapy; tectonic penetrating keratoplasty; anterior chamber tap; intracameral voriconazole, amphotericin B, and cefuroxime; and a partial conjunctival flap. Pathology from the cornea showed GMS and PAS stains positive for fungal forms. C. dubliniensis is a yeast closely related to Candida albicans that was first described in 1995 as a cause of oral candidiasis in patients with AIDS. There are a few published cases of endophthalmitis due to C. dubliniensis in the ophthalmology literature, but to our knowledge, no cases of fungal keratitis due to this organism have been reported. C. dubliniensis is a novel cause of fungal keratitis that can be difficult to identify and treat but is felt to be less virulent than C. albicans and generally susceptible to available anti-fungal therapies.

Rare case of exogenous Candida dubliniensis endophthalmitis: a case report and brief review of the literature

Background

Candida dubliniensis is a recently described opportunistic fungal pathogen that rarely infects the eye. Reported cases of C. dubliniensis endophthalmitis have been of endogenous etiology and demonstrated recovery of visual acuity with timely treatment. We herein report an unusual case of severe C. dubliniensis endophthalmitis requiring enucleation.

Findings

This is a retrospective, descriptive case report with a brief literature review. A 41-year-old Caucasian man, with a history of blunt trauma 8 months prior, presented to the emergency department with left eye pain and loss of vision 2 days after complicated cataract surgery. He was first evaluated by an outside ophthalmologist 3 months after trauma for left eye pain and progressive vision loss. He was found to have light perception vision with non-granulomatous anterior uveitis but no sign of ruptured globe. A dense cataract developed while he was treated with topical and subtenon's corticosteroids for which he underwent cataract surgery. Our examination revealed no light perception vision with a relative afferent pupillary defect, elevated intraocular pressure, moderate anterior chamber reaction, pupillary membrane, vitritis, and choroidal thickening on B-scan ultrasonography. Diagnostic vitrectomy revealed purulent vitreal debris, retinal detachment with severe retinal necrosis, and choroidal infiltrates. Operative fungal cultures grew C. dubliniensis. Despite intravitreal and systemic anti-fungal treatment, vision and pain did not improve, resulting in subsequent enucleation.

Conclusion

C. dubliniensis endophthalmitis is uncommonly encountered and typically has reasonable visual outcomes. This is the first reported case of C. dubliniensis, likely exogenous endophthalmitis, resulting in enucleation, illustrating the potential virulence of this newly described organism.