Exogenous cryptococcal endophthalmitis in an immunocompetent patient

We describe a case of exogenous cryptococcal endophthalmitis without central nervous system (CNS) involvement or systemic infection in an immunocompetent patient. An 82-year-old male with hypertension, hyperlipidemia, type 2 diabetes mellitus, and primary open-angle glaucoma with a history of left eye trabeculectomy presented with 3 months of worsening left eye pain and redness. Vitreous cultures resulted as Cryptococcus, prompting treatment with intravitreal amphotericin and further investigation. Systemic workup was unrevealing for an endogenous source, CNS involvement, or immunocompromising conditions. He was treated with an aggressive regimen of systemic antifungals, leading to subjective improvements in clinical exam and in vision.

An atypical presentation of giant cell arteritis: Fatigable signs to anterior ischemic optic neuropathy and choroidal infarction

KEY CLINICAL MESSAGE

Prompt diagnosis and treatment of GCA are crucial to preserve vision. Because of this, new-onset ptosis or diplopia in elderly patients should warrant consideration of GCA, even in the absence of "classic" features, systemic symptoms or elevated inflammatory markers.

ABSTRACT

Giant cell arteritis (GCA) is a vision-threatening, ophthalmic emergency that classically presents with new-onset headaches, scalp tenderness, systemic symptoms, visual disturbances, and elevated inflammatory markers. We describe an atypical presentation of GCA in an 87-year-old patient with fatigable ptosis and diplopia, with subsequent anterior ischemic optic neuropathy and choroidal infarction.

Inflammatory Myofibroblastic Tumor of the Orbit in a 5-Month-Old Infant

Inflammatory myofibroblastic tumors are mesenchymal neoplasms composed of spindle cells and inflammatory infiltrate. The authors describe a 5-month-old infant with orbital inflammatory myofibroblastic tumor, the youngest patient currently reported in the literature. The histo-pathology, orbital apex location, and patient's age led to a chemotherapy-driven treatment using crizotinib with near-complete resolution of the tumor. [J Pediatr Ophthalmol Strabismus. 2022;59(2):e25-e28.].

Actinomyces ductular dacryoadenitis resulting in a lacrimal gland abscess

Lacrimal gland ductulitis is a rare infection of the lacrimal gland ductules. Individuals affected report a history of chronic mucopurulent conjunctivitis with "stringy" discharge. All patients are clinically noted to have an inflamed lacrimal gland ductule. Prior reports have suggested Actinomyces species as the "probable" etiology.We report the findings of a 42-year-old male found to have lacrimal gland ductulitis with a lacrimal gland abscess, confirmed by radiologic studies. Surgical drainage was necessitated and performed. Histopathologic analysis confirmed colonization by Actinomyces species, as well as the presence of sulfur granules. To our knowledge, this is the first report of Actinomyces lacrimal gland ductulitis resulting in a secondary lacrimal gland abscess.

Ophthalmia neonatorum as the presenting sign of SARS-CoV-2

The most common ocular manifestation of SARS-CoV-2 in adults and children is acute conjunctivitis. We report the case of a 4-day-old infant who presented with acute-onset mucopurulent discharge of the left eye as well as subconjunctival hemorrhage and palpebral injection, without corneal findings. A diagnosis of ophthalmia neonatorum was established, for which ocular cultures and Gram staining were performed. No bacterial growth was noted, and polymerase chain reaction (PCR) testing for Chlamydia trachomatis, Neisseria gonorrhea, and herpes simplex were negative. Nasopharyngeal and conjunctival SARS-CoV-2 PCR were positive. Given the identification of SARS-CoV-2 illness, lack of other underlying bacterial or viral etiology on testing, and the well-documented ability for SARS-CoV-2 to cause conjunctivitis, the clinical picture was supportive of ophthalmia neonatorum secondary to SARS-CoV-2. The infant was treated with ceftriaxone and azithromycin prior to culture results. During admission, no systemic findings of Covid-19 illness were observed.

Natural killer T-cell lymphoma causing bilateral recurrent recalcitrant dacryocystitis

A 35-year-old female with a history of chronic extensive rhinosinusitis, previously treated twice with functional endoscopic sinus surgery, presented with recurrent dacryocystitis despite prior dacryocystorhinostomy. Histopathological specimens taken at the most recent sinus surgery demonstrated a lymphocytic inflammatory reaction without evidence of angiodestruction or necrosis. Flow cytometry was normal. Over the following 9 months, the patient developed worsening hypertelorism and bilateral recurrent acute dacryocystitis with a fistula tract to the skin. Neuroimaging revealed a hyperintense enhancing soft tissue expansion into the periorbital regions, invading the nasolacrimal canals, and obstructing the paranasal sinuses. A skin biopsy at the fistula site revealed natural killer T-cell lymphoma. Metastatic work-up disclosed lung, spleen, and bone marrow involvement. The patient underwent chemotherapy with mixed clinical response, and ultimately passed away from metastatic disease. The authors present a rare case of natural killer T-cell lymphoma involving the nasolacrimal sac, presenting as recurrent dacryocystitis and diagnosed by skin biopsy of the fistula site.

Thrombosed orbital arteriovenous malformation in a patient with lymphangioleiomyomatosis

A 47 year-old female with lymphangioleiomyomatosis developed right periorbital pain worsened while chewing, six months prior. Neuroimaging demonstrated a heterogenous inferotemporal right orbital mass extending through the inferior orbital fissure into the temporalis fossa, with flow voids. Given the patient's past medical history, the lesion was presumed to be a perivascular epithelioid cell tumor, a manifestation of lymphangioleiomyomatosis. A lateral orbitotomy revealed a well-circumscribed bluish-red lesion with areas of hemorrhage that was resected in total. Histopathology, however, was consistent with a thrombosed orbital arteriovenous malformation likely arising from the zygomaticotemporal neurovascular bundle. Lymphangioleiomyomatosis is a rare progressive disease that causes cystic destruction of the lungs and is frequently associated with extrapulmonary tumor infiltration, typically of the kidney and liver. Lymphangiomyoleiomyomatosis cell pathogenesis includes a pro-angiogenic micro-environment, classically expressing vascular endothelial factor-C and -D, which we postulate may have contributed to the development of the orbital arteriovenous malformation.