Aspergillus aortitis in an immunocompetent patient presenting with acute endophthalmitis

Clinical features, treatment and prognosis of patients with endogenous infectious endophthalmitis

PURPOSE

To investigate whether the clinical characteristics, treatment and prognosis of endogenous infectious endophthalmitis (EIE) have changed over the past 5 years.

METHODS

Retrospectively analyze all articles about EIE published in the PubMed, Web of Science, and Embase databases from 2017 to 2021.

RESULTS

A total of 128 patients and 147 eyes (46 left and 60 right) were included in the study. The mean age at diagnosis was 51 ± 19 years. The most common risk factors were diabetes and intravenous drug use. From 2017 to 2021, Klebsiella was the most common pathogenic microorganism (22%), and vitreous culture had the highest positivity rate. The most common complaint was blurred vision. The mean visual acuity (logMAR) at onset was 2.84, and the clinical symptoms were vitreal inflammation and opacity (63%), ocular pain (37%), and conjunctival congestion (36%). The ocular inflammation could be reduced by intraocular antibiotics or vitrectomy. However, the visual prognosis, with a mean logMAR of 2.73; only 50% of the eyes reached a visual acuity level of finger count and above. Changes in diagnostics over the past 5 years have mainly manifested as more diverse microorganism culture methods. In addition to conventional culture methods, PCR, sputum culture and aqueous humour culture are also commonly used for the diagnosis of pathogenic bacteria, improving the positive culture rate and visual prognosis.

CONCLUSION

The prognosis of EIE is poor. It is recommended to pay attention to the pathogenic bacteria culture results and accompanying systemic diseases and to diagnose and treat patients as soon as possible.

Endogenous Intraocular Aspergillus Infection Associated With Systemic Vasculitis

We report the systemic, ocular, and investigational findings of a 51-year-old male patient with large-vessel vasculitis and presumed ocular Aspergillus infection. He presented with persistent fever with left-sided weakness of the upper and lower limb for the past 15 days accompanied by profound visual loss in the left eye. A neurological examination revealed a left-sided ataxic hemiparesis with a significant reduction of power in both upper and lower limbs with dysarthria. He underwent neuroimaging which revealed a fresh non-hemorrhagic infarct in the left thalamocapsular and left parieto-occipital regions, suggestive of a stroke. A positron emission tomography/computed tomography scan revealed a diffuse low-grade uptake (standardized uptake value = 3.6) associated with a circumferential wall thickening involving the ascending aorta, arch of the aorta, and descending and abdominal aorta, suggestive of active large-vessel vasculitis. On examination, his visual acuity was 6/9 unaided in the right eye and perception of light with inaccurate projection in the left. A dilated fundus examination revealed multiple hemorrhages, cotton-wool spots, and areas of retinal thickening associated with a hard exudate in the right eye. A similar picture was seen in the left eye with the additional findings of a large (1 DD x 1 DD) subretinal whitish-yellowish mass with surrounding superficial retinal hemorrhages in the superior quadrant. A B-scan through the subretinal revealed non-visualization of the retinal pigment epithelium-Bruchs membrane layer with a large subretinal mass with a basal hyporeflective area and hyperreflective areas superiorly, suggesting a choroidal Aspergillus infection with infiltration of the overlying retina but without vitreous seeding. He was treated with anti-epileptics, oral and injectable blood thinners, oral antihypertensives, and oral antidiabetic medication. Intravenous methylprednisolone 1 g once daily was administered for five days, followed by oral prednisolone in tapering doses. In view of the ocular findings and the presumed diagnosis of ocular aspergillus, oral voriconazole 400 mg daily was added. At the last follow-up, the subretinal mass had completely resolved with a residual area of pigmentary degeneration with loss of retinal layer differentiation on the B-scan. There was also a marked reduction in the hemorrhages and cotton-wool spots in either eye, suggesting a marked improvement of the retinal vasculitis. A larger dataset would be needed to confirm a potential causative role for systemic fungal infections in large-vessel vasculitis.

Aspergillus Endophthalmitis: Epidemiology, Pathobiology, and Current Treatments

Fungal endophthalmitis is one of the leading causes of vision loss worldwide. Post-operative and traumatic injuries are major contributing factors resulting in ocular fungal infections in healthy and, more importantly, immunocompromised individuals. Among the fungal pathogens, the Aspergillus species, Aspergillus fumigatus, continues to be more prevalent in fungal endophthalmitis patients. However, due to overlapping clinical symptoms with other endophthalmitis etiology, fungal endophthalmitis pose a challenge in its diagnosis and treatment. Hence, it is critical to understand its pathobiology to develop and deploy proper therapeutic interventions for combating Aspergillus infections. This review highlights the different modes of Aspergillus transmission and the host immune response during endophthalmitis. Additionally, we discuss recent advancements in the diagnosis of fungal endophthalmitis. Finally, we comprehensively summarize various antifungal regimens and surgical options for the treatment of Aspergillus endophthalmitis.

Incidental Finding of an Aspergillus Pseudoaneurysm in the Ascending Aorta of an Immunocompetent Patient

Pseudoaneurysms of the ascending aorta are rare, yet they are life-threatening conditions and usually associated with poor outcomes due to insidious presentation. Many different etiologies have been associated with aortic pseudoaneurysms including; atherosclerosis, infections, connective tissue disorders, and traumatic causes. In addition, aortic pseudoaneurysms have been reported following thoracic surgeries, including aortic valve replacements, aortic dissection repair, and coronary artery bypass grafting. Aspergillus is amongst the infectious etiologies of pseudoaneurysms. Aspergillus species is a ubiquitous mold (fungus) that is mostly harmless but may result in serious illnesses in immunocompromised hosts with hematologic neoplasms, neutropenia, or immunodeficiency syndromes. In this paper, we report a case of an ascending aortic pseudoaneurysm caused by Aspergillus infection. To our knowledge, this is an exceptionally rare case diagnosed incidentally in an immunocompetent patient, who is surgically free and without any pre-existing risk factors.

Diagnostic and Management Strategies of Aspergillus Endophthalmitis: Current Insights

Fungal endophthalmitis is subsequent to endogenous or exogenous infection and represents an important complication of ocular surgery which may lead to significant visual loss and blindness. The prognosis is poor because of delayed diagnosis and limited availability of effective antifungal drugs with good ocular penetration. Furthermore, the critical issue in diagnosing fungal infection of the eye is microbiological identification of the etiologic agent in clinical samples. Aspergillus is among the most frequent isolated organisms in fungal endophthalmitis. Early diagnosis is essential to prevent severe complications and blindness. Treatments include local, systemic and surgical therapeutic strategies. The purpose of the present review is the analysis of the current procedures adopted to promptly diagnose and treat Aspergillus endophthalmitis.

Fungal Endogenous Endophthalmitis Secondary to Magnusiomyces capitatus

We report the case of a 68-year-old immunocompetent patient with a dilatation of the ascending aorta, intraluminal vegetations, and pseudoaneurysmatic bulging who presented with unilateral fungal endogenous endophthalmitis 8 days after coronary angiogram. The isolated pathogen resulted to be Magnusiomyces capitatus, a filamentous, yeast-like fungus that can be commonly found in normal human microflora, with an immunosuppression-related pathogenicity. A literature research revealed a single case of ophthalmic infection – a keratitis – caused by this pathogen. Furthermore, we add a review of mycotic endophthalmitis related to aortic infection.