Bilateral endogenous Candida albicans subretinal abscess with suspected mixed bacterial infection

Subretinal abscess: causative pathogens, clinical features and management

Purpose

To review the literature on endogenous subretinal abscess (SRA).

Methods

We searched in the literature for the terms ‘subretinal abscess’, ‘chorio-retinal abscess’ and ‘choroidal abscess’.

Results

A total of 122 patients were identified, of whom 20 patients (22 eyes) had no identified systemic infective foci (group 1) and 102 (120 eyes) had systemic infective foci (group 2). The mean age for group 1 was 44.6 years (range 2 weeks-82 years) and for group 2 was 43.2 years (range 1–89 years). The responsible pathogen was identified in 90% and 95% of cases, respectively. In group 1 the most frequent causative agents were Aspergillus and Nocardia, while in group 2 were Nocardia, Mycobacterium Tuberculosis and Klebsiella. In both groups the most common symptoms were reduced vision (70% and 72.5%, respectively), pain (65% and 29.4%, respectively) and redness (35% and 17.6%, respectively). For group 1 there was no difference between mean initial and final visual acuity (1.7 logMAR, range 0–3 logMAR), while for group 2 mean initial and final visual acuities were 0.8 logMAR and 0.6 logMAR, respectively. Final visual acuity was significantly better in group 2 (p = 0.003). Anterior segment inflammation was seen in 77.3% of cases of group 1 and 66.7% of cases of group 2. In both groups the abscess most common locations were posterior pole (45.4% and 32.5%, respectively) and temporal periphery (13.6% and 13.3%, respectively). Clinical features included hemorrhages (76.5% and 76.3%, respectively) and subretinal fluid (75% in both groups). Diabetes mellitus (20% and 25.5%) and immunosuppressive drug intake (35% and 23.5%) were the main predisposing factors for SRA. Combination of systemic and intravitreal antibiotics/antifungals and vitrectomy was the main therapeutic strategy for both groups. Systemic treatment alone was used mainly for cases of tubercular etiology. The timing of vitrectomy differed between the two groups, as it more commonly followed the use of systemic and intravitreal antibiotics in the forms associated with systemic infective foci. Additional abscess drainage or intralesional antibiotics were performed in 23.8% of cases.

Conclusion

At present no guideline exists for the treatment of subretinal abscess. Systemic broad-spectrum antibiotic treatment is of primary importance and should be used in all cases unless contraindicated. Combination of systemic and local treatment is the most frequently adopted strategy.

Candida Albicans Sub-Retinal Abscess following COVID-19

A 42-year-old male post-renal transplantation presented with sudden diminution of vision in the left eye. The right eye was lost following a failed vitreoretinal surgery 5 years ago. The patient had been hospitalized 4 months prior for coronavirus disease 2019 infection with a good recovery. The presenting visual acuity was 20/600 in the right eye and 20/250 in the left eye. Fundus examination revealed a sub-macular sub-retinal abscess in the left eye. Sub-retinal aspiration of the abscess revealed Candida albicans. The patient was managed with repeated intravitreal amphotericin B injections, following which the abscess resolved with scarring and vision improving to 20/60.

Subretinal abscess due to Candida tropicalis in a patient with acute myeloid leukaemia: Case report

A 54-year-old female patient with a history of acute myeloid leukaemia and receiving maintenance chemotherapy had a systemic relapse. She also had candidaemia caused by Candida tropicalis. Her blood cultures were negative after receiving antifungal treatment. Later, she had an ophthalmological assessment as part of the protocol, without ocular discomfort. In the fundoscopic examination, a whitish chorioretinal lesion was found in the left eye in relation to subretinal abscess, which correlated with retinal angiography and optical coherence tomography. The patient was treated with systemic antifungals with a favourable resolution of the lesion.

Subretinal abscess due to Candida tropicalis in a patient with acute myeloid leukaemia: case report

A 54-year-old female patient with a history of acute myeloid leukaemia and receiving maintenance chemotherapy had a systemic relapse. She also had candidaemia caused by Candida tropicalis. Her blood cultures were negative after receiving antifungal treatment. Later, she had an ophthalmological assessment as part of the protocol, without ocular discomfort. In the fundoscopic examination, a whitish chorioretinal lesion was found in the left eye in relation to subretinal abscess, which correlated with retinal angiography and optical coherence tomography. The patient was treated with systemic antifungals with a favourable resolution of the lesion.

Sub-retinal abscess as presenting feature of endogenous Candida endophthalmitis

BACKGROUND

Sub-retinal abscess as the presenting feature in the setting of endogenous fungal endophthalmitis is extremely infrequent. Immunodeficiency states are major predisposing risk factors. To the best of our knowledge, this is the first case report of Candida sub-retinal abscess as initial presentation in an immunocompetent patient.

CASE PRESENTATION

A 32-year old, generally fit and well, female presented to us with gradually deteriorating vision in her right eye. Visual acuity was counting fingers in the right eye and, 20/30 in the left eye. Right eye fundus examination showed a full thickness, yellowish-white foveal lesion, and significant vitreous haze. Left eye examination was normal. Upon direct questioning, the patient disclosed history of backstreet abortion 3 weeks prior to the onset of her ocular symptoms. She underwent vitreous tap and intravitreal antibiotics (amphotericin B, 5 μg/0.5 ml). Vitreous culture showed profuse growth of Candida albicans. Because her condition was progressively deteriorating, she underwent 25 g vitrectomy plus repeat intravitreal amphotericin B under general anaesthesia. Three weeks post-vitrectomy, vitreous inflammation resolved completely, and the sub-retinal abscess healed with a macular scar formation. Over a follow-up of 4 years, no recurrences were observed.

CONCLUSION

Our case highlights the importance of considering Candida albicans infection in the differential diagnosis of sub-retinal abscesses. Although immunocompromised states are traditionally identified as predisposing factors for fungal infections, fungal endogenous endophthalmitis can occur in healthy individuals as well.

FUSARIUM SOLANI SUBRETINAL ABSCESS IN A PATIENT WITH ACUTE MYELOID LEUKEMIA

PURPOSE

To report on a case of Fusarium solani subretinal abscess in a patient with acute myeloid leukemia treated with an allogenic bone marrow transplant.

METHODS

A 47-year-old male with a history of acute myeloid leukemia with intermediate cytogenetic risk was admitted in our hospital. The disease relapsed after two cycles of chemotherapy. He was then treated with an allogenic bone marrow transplant, with busulfan, cyclophosphamide, and thymoglobulin. One week after the procedure, a sepsis of unknown origin in neutropenia occurred. Blood cultures and sputum were negative for bacteria and fungi. At the eighth week after the procedure, the patient had acute vision loss of the right eye. Funduscopy in the right eye revealed an inferior temporal yellowish white elevated lesion of approximately 10 disk areas and superficial perifoveal and perilesional hemorrhages.

RESULTS

Vitrectomy was performed and samples from the vitreous and the subretinal abscess material were sent for analysis. Vitreous and subretinal specimens grew colonies of a fungus morphologically consistent with F. solani.

CONCLUSION

Fusarium solani should be included in the differential diagnosis of subretinal abscesses.

Intralesional antibiotic injection using 41G needle for the management of subretinal abscess in endogenous endophthalmitis

BACKGROUND

Presence of subretinal abscess in endogenous endophthalmitis indicates a more severe form of infection. Available reports indicate variable response to standard treatment with systemic, intravitreal pharmacotherapy and vitreous surgery. There are no reports citing the possible role of intralesional antibiotic therapy in managing subretinal abscess.

CASE PRESENTATION

A 30 year old lady presented with features of endogenous endophthalmitis and subretinal abscess. Presenting vision was finger counting close to face. Despite prompt initiation of systemic antibiotics and intravitreal injection, no response was noted. 25G pars plana vitrectomy was performed along with injection of vancomycin directly into the subretinal abscess, using a 41G needle. Postoperative course was uneventful and the abscess showed signs of rapid resolution. Visual acuity improved to 6/24.

CONCLUSION

Intralesional pharmacotherapy may be safe and effective in the treatment of subretinal abscess associated with endogenous endophthalmitis.