Endogenous Fungal Endophthalmitis in a Patient Admitted to Intensive Care and Treated with Systemic Steroid for COVID-19

New and emerging roles for inhalational and direct antifungal drug delivery approaches for treatment of invasive fungal infections

INTRODUCTION

The rising prevalence of difficult-to-treat, deep-seated invasive fungal diseases (IFD) has led to high mortality. Currently available antifungal treatments, administered predominantly orally or intravenously, may not sufficiently penetrate certain body sites, and/or are associated with systemic toxicity. Little is known about how to position alternative administration approaches such as inhalational and direct drug delivery routes.

AREAS COVERED

This review provides an updated overview of unconventional drug delivery strategies for managing IFD, focusing on inhalational (to target the lungs) and direct delivery methods to the central nervous system, bone/joint, and eyes. Novel compounds (e.g. opelconazole) and existing antifungals with innovative drug delivery systems currently undergoing clinical trials and/or used off-label in the clinical setting are discussed.

EXPERT OPINION

For both inhalational agents and direct delivery approaches, there are similar challenges that include the absence of: approved formulations for specific administration routes, delivery vehicles that are simple and safe to use whilst maintaining potency and efficiency of delivery, animal models suitable for investigating pharmacokinetic/pharmacodynamic profiles of inhaled antifungals, and consensus on the composite endpoints and intervals for of follow-up in clinical trials. To meet these challenges, cooperation of all stakeholders in drug development and regulation is required.

Endogenous Endophthalmitis Associated With COVID-19: A Systematic Review on Its Incidence, Risk Factors, Causative Organisms, and Prognosis

Endogenous endophthalmitis (EE) is a rare but severe intraocular infection resulting from hematogenous dissemination of microorganisms. During the COVID-19 pandemic, there has been a notable increase in EE cases. This literature review aims to evaluate studies focusing on EE associated with COVID-19 to elucidate its pathogenesis and optimize patient management strategies. A thorough search was conducted across PubMed, ScienceDirect, and Google Scholar for relevant research. The surge in EE cases during the COVID-19 pandemic is likely linked to alterations in immune status and systemic comorbidities exacerbated by the virus and its treatments. Notably, Candida albicans and Aspergillus species emerged as the predominant fungal pathogens in these cases. The findings suggest that the increased incidence of EE is associated with immune dysregulation and increased vulnerability of COVID-19 patients, particularly those with severe diseases or undergoing immunosuppressive treatments. Early diagnosis with timely and effective treatment is crucial for improving patient outcomes. Regular ophthalmic evaluations for hospitalized COVID-19 patients are strongly advised to detect and address ocular complications early.

Ocular manifestations of COVID-19

There is an increasing body of knowledge regarding how COVID-19 may be associated with ocular disease of varying severity and duration. This article discusses the literature on the ocular manifestations associated with COVID-19, including appraisal of the current evidence, suggested mechanisms of action, associated comorbidities and risk factors, timing from initial infection to diagnosis and clinical red flags. The current literature primarily comprises case reports and case series which inevitably lack control groups and evidence to support causality. However, these early data have prompted the development of larger population-based and laboratory studies that are emerging. As new data become available, a better appraisal of the true effects of COVID-19 on the eye will be possible. While the COVID-19 pandemic was officially declared no longer a "global health emergency" by the World Health Organization (WHO) in May 2023, case numbers continue to rise. Reinfection with different variants is predicted to lead to a growing cumulative burden of disease, particularly as more chronic, multi-organ sequelae become apparent with potentially significant ocular implications. COVID-19 ocular manifestations are postulated to be due to three main mechanisms: firstly, there is a dysregulated immune response to the initial infection linked to inflammatory eye disease; secondly, patients with COVID-19 have a greater tendency towards a hypercoagulable state, leading to prothrombotic events; thirdly, patients with severe COVID-19 requiring hospitalisation and are immunosuppressed due to administered corticosteroids or comorbidities such as diabetes mellitus are at an increased risk of secondary infections, including endophthalmitis and rhino-orbital-mucormycosis. Reported ophthalmic associations with COVID-19, therefore, include a range of conditions such as conjunctivitis, scleritis, uveitis, endogenous endophthalmitis, corneal graft rejection, retinal artery and vein occlusion, non-arteritic ischaemic optic neuropathy, glaucoma, neurological and orbital sequelae. With the need to consider telemedicine consultation in view of COVID-19's infectivity, understanding the range of ocular conditions that may present during or following infection is essential to ensure patients are appropriately triaged, with prompt in-person ocular examination for management of potentially sight-threatening and life-threatening diseases.

Bilateral endogenous Candida albicans endophthalmitis following COVID-19 infection and intravenous antibiotics use: A case report

Key Clinical Message

Endogenous fungal endophthalmitis tends to occur in immunocompromised patients, including COVID-19 infection. For high-risk populations, timely tissue biopsy, fungal culture, and susceptibility testing can facilitate early diagnosis and treatment, thereby improving the prognosis.

Abstract

While endogenous fungal endophthalmitis is a rare condition, its incidence has recently been on the rise. A 48-year-old male presented with complaints of acute visual loss in his right eye for 2 weeks. He had a history of COVID-19 infection, confirmed by a positive nucleic acid test, and was treated with intravenous antibiotics and glucocorticoids a week before the episode. A comprehensive eye examination revealed significant inflammatory cells floating in the anterior chamber and considerable cloudiness in the vitreous of the right eye, while few vitreous cells were visualized in the left eye. After pars plana vitrectomy (PPV) was performed in the right eye, a vitreous biopsy revealed an intravitreal infection of Candida albicans, which was susceptible to fluconazole. Endogenous fungal endophthalmitis occurs in patients with various underlying systemic conditions, such as those with diabetes, organ transplantation recipients, individuals undergoing chemotherapy, users of corticosteroids and immunosuppressants, AIDS patients, and those engaged in intravenous drug use. In high-risk populations associated with intravenous antibiotics, the timely identification of one or more well-defined oval yellow-white chorioretinal lesions, especially in the posterior pole of the retina, can contribute to an early diagnosis through tissue biopsy, fungal culture, and susceptibility testing. This approach enables targeted antifungal therapy, thereby improving the prognosis of visual function for the patient.

Endogenous fungal endophthalmitis following COVID-19 infection with microbiological and molecular biological correlation - A report of two cases

This case report describes three eyes of two patients, who were diagnosed to have endogenous fungal endophthalmitis post coronavirus disease 2019 (COVID-19) infection. Both patients underwent vitrectomy with intravitreal anti-fungal injection. Intra-ocular samples confirmed the fungal etiology by conventional microbiological investigations and polymerase chain reaction in both cases. The patients were treated with multiple intravitreal and oral anti-fungal agents; however, vision could not be salvaged.

Endogenous Fungal Endophthalmitis following COVID-19 Hospitalization: Evidence from a Year-Long Observational Study

PURPOSE

To describe cases of endogenous fungal endophthalmitis (EFE) post-recovery from or hospitalization for coronavirus disease 2019 (COVID-19).

METHODS

This prospective audit involved patients with suspected endophthalmitis referred to a tertiary eye care center over a one-year period. Comprehensive ocular examinations, laboratory studies, and imaging were performed. Confirmed cases of EFE with a recent history of COVID-19 hospitalization±intensive care unit admission were identified, documented, managed, followed up, and described.

RESULTS

Seven eyes of six patients were reported; 5/6 were male, and the mean age was 55. The mean duration of hospitalization for COVID-19 was approximately 28 days (14-45); the mean time from discharge to onset of visual symptoms was 22 days (0-35). All patients had underlying conditions (5/6 hypertension; 3/6 diabetes mellitus; 2/6 asthma) and had received dexamethasone and remdesivir during their COVID-related hospitalization. All presented with decreased vision, and 4/6 complained of floaters. Baseline visual acuity ranged from light perception (LP) to counting fingers (CF). The fundus was not visible in 3 out of 7 eyes; the other 4 had "creamy-white fluffy lesions" at the posterior pole as well as significant vitritis. Vitreous taps were positive for Candida species in six and Aspergillus species in one eye. Anti-fungal treatment included intravenous amphotericin B followed by oral voriconazole and intravitreal amphotericin B. Three eyes underwent vitrectomy; the systemic health of two patients precluded surgery. One patient (with aspergillosis) died; the others were followed for 7-10 months - the final visual outcome improved from CF to 20/200-20/50 in 4 eyes and worsened (hand motion to LP) or did not change (LP), in two others.

CONCLUSION

Ophthalmologists should maintain a high index of clinical suspicion for EFE in cases with visual symptoms and a history of recent COVID-19 hospitalization and/or systemic corticosteroid use - even without other well-known risk factors.