CHRONIC ENDOPHTHALMITIS DUE TO PYRENOCHETA ROMEROI IN AN IMMUNOCOMPETENT HOST—A CASE REPORT FROM SOUTHERN INDIA Kalpana Babu, DO, MRCOphth (Lon),* Praveen R. Murthy, MS,* Peralam Y. Prakash, MSc, PhD,† Jyoti Kattige, MS,* Sukanya Rangaswamy, MD,‡ Vinay R. Murthy, MS,* Krishna R. Murthy, DO, MRCOphth (Lon)*
Purpose: Endophthalmitis due to Pyrenochaeta romeroi has not been reported in literature (PubMed, Medline). We report an interesting case of P. romeroi causing chronic endophthalmitis in an immunocompetent lady. Methods: Retrospective interventional case report. A 25-year-old immunocompetent lady presented with pain and redness in the left eye of 1-month duration. Her best-corrected visual acuity was 6/6 and 6/18 in the right and the left eyes, respectively. Slit-lamp examination of the left eye showed a corneal stromal scar, fibrinlike material in the anterior chamber, few retrolental cells, and normal fundus examination. Results: Aqueous taps on two occasions were negative for bacteria and fungi on routine smear, culture, and nested polymerase chain reaction. As inflammation recurred despite intravitreal voriconazole and amikacin injections, a lensectomy with vitrectomy was done. During vitrectomy, dense flocculent material was seen in the pars plana with only scleral indentation. The flocculent material grew a rare filamentous fungus called P. romeroi. The left eye underwent retinal detachment surgery with silicone oil insertion for a giant retinal tear at 2 months of follow-up. At 6 months of follow-up, her vision in the left eye was stable at 6/24 (Snellen) with no ocular inflammation. Conclusion: P. romeroi may need to be added in the list of rare fungi, which cause chronic endophthalmitis. RETINAL CASES & BRIEF REPORTS 8:197–199, 2014
From the *Department of Intraocular Inflammation and Vitreoretinal Services, Vittala International Institute of Ophthalmology and Prabha Eye Clinic and Research Center, Bangalore, India; †Department of Medical Mycology, Kasturba Medical College, Manipal, India; and ‡Department of Microbiology and Infection Control, Fortis Hospitals, Bangalore, India.
Case Report A 25-year-old immunocompetent lady was referred with a history of pain and redness in the left eye of 1-month duration. Her local ophthalmologist had noticed a white lesion in the left eye and started her on oral fluconazole of 200 mg 2 times a day, and on natamycin and moxifloxacin eye drops 6 times a day. Systemic history was significant for treatment for infertility. She had no history of diabetes mellitus or trauma. On examination, her best-corrected visual acuity was 6/6 and 6/18 in the right and left eyes, respectively. Slit-lamp examination (in the left eye) showed a corneal stromal scar, flocculent mass in the anterior chamber, a small posterior synechia at 7-o’clock position, and few retrolental cells (Figure 1A). Fundus examination was normal. An aqueous tap was negative for bacteria and fungi on smear, culture, and polymerase chain reaction. She was started on hourly voriconazole (1%) eye drops, fortified amikacin (8 mg/mL)
E
ndophthalmitis due to Pyrenochaeta romeroi has not been reported in literature (PubMed, Medline). We report an interesting case of P. romeroi causing chronic endophthalmitis in an immunocompetent lady. 197
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Fig. 1. A. Slit-lamp photograph of the left eye showing a corneal scar and flocculent material in the anterior chamber. B. Slit-lamp photograph of the left eye showing an increase in the flocculent material seen in the anterior chamber after a month.
Fig. 2. A. Culture plate shows olivaceous growth on the Sabouraud’s dextrose agar. B. Microphotograph showing hyaline septate hyphae with very scanty sporing bodies. The hyaline hyphae with well-developed ascus bodies.
eye drops, and oral ketoconazole of 200 mg 2 times a day. She came back 2 weeks later with an increase in pain and redness. The flocculent mass had increased and a plaque was seen on the lens (Figure 1B). This was removed along with the aqueous, and was sent for repeat smear, culture, and polymerase chain reaction for bacteria and fungi. Although the specimen was negative for bacteria and fungi, intravitreal voricanozole and intracameral injections of amikacin were given in view of the strong clinical suspicion. She came back 1 month later with a decrease in vision to 6/60, an inferonasal corneal edema, inferonasal organized flocculent material, bulky iris from 7-’o clock to 9-’o clock positions, and a creamy white membrane on lens capsule. Lensectomy with vitrectomy and intravitreal injections of voriconazole and amphotericin B were given. During vitrectomy, whitish flocculent material was seen in the pars plana on scleral indentation (see Video, None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web Site (www.retinajournal.com). Reprint requests: Kalpana Babu, DO, MRCOphth (Lon), Prabha Eye clinic & Research center, 504, 40th Cross, Jayanagar, 8th block, Bangalore 560070, India; e-mail: kalpana@ prabhaeyeclinic.com
Supplemental Digital Content 1, http://links.lww.com/ICB/A9). The undiluted vitreous including the flocculent material grew P. romeroi on culture after 5 days. The same was confirmed by two independent laboratories in the state (P.Y.P. and S.R.). Two months later, she developed total retinal detachment because of a giant retinal tear. She underwent vitrectomy with silicone oil insertion. At 6 months of follow-up, her best-corrected visual acuity was 6/24 in the left eye, and her eye was stable with no recurrences of inflammation.
Description of the Fungus The colonies were restricted, velvety-to-dark olive gray with an olivaceous reverse on Sabouraud’s dextrose agar (Figure 2A). The setae were abundant around the ostiole, dark brown, thick and smoothwalled, septate, and tapering toward the tip. The conidiophores ampulliform, hyaline, and septate emerged from all over the inner surface of the pycnidial wall were branched at the base, bearing terminal and lateral conidiogenous cells. The slide culture microscopy showing hyaline septate and
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hyphae with very scanty sporing bodies. The hyaline hyphae had ascus bodies (Figure 2B).
initial aqueous taps being negative probably because of decreased load of the fungus in the aqueous while the vitreous, obtained near the flocculent material in the pars plana, grew the fungus. With this case, P. romeroi may need to be added in the list of rare fungi causing chronic endophthalmitis.4
Discussion The coelomyceteous fungal genus Pyrenochaeta has three medically important species: Pyrenochaeta mackinnonii, Pyrenochaeta unguis-hominis, and P. romeroi.1 P. romeroi are often incriminated as agents of mycetoma,1 and to date, there are no reports of P. romeroi causing endophthalmitis in literature (Medline search). P. romeroi is a rare fungus that can cause keratitis.2,3 These fungi normally occur as a soil saprobe and on plant debris, and thus one can speculate the route of entry in our patient because the cornea was highlighted by a corneal scar, with probable initial keratitis and then evolved into endophthalmitis. The identification of a rare fungus is often not easy because it is not part of the spectrum of fungi regularly encountered in clinical samples. In our case, the challenge was in the diagnosis due to
Key words: chronic endophthalmitis, fungus, Pyrenochaeta romeroi. References 1. De Hoog GS, Guarro J, Gene J, Figueras MJ. Atlas of Clinical Fungi. 2nd ed. Utrecht, the Netherlands: Centraalbureau voor Schimmelcultures; 2000. 2. Ferrer C, Pérez-Santonja JJ, Rodríguez AE, et al. New Pyrenochaeta species causing keratitis. J Clin Microbiol 2009;47:1596–1598. 3. Gopinathan U, Garg P, Fernandes M, et al. The epidemiological features and laboratory results of fungal keratitis: a 10-year review at a referral eye care center in south India. Cornea 2002;21:555–559. 4. Chakrabarti A, Shivaprakash MR, Singh R, et al. Fungal endophthalmitis: fourteen years’ experience from a center in India. Retina 2008;28:1400–1407.
Purpose: Endophthalmitis due to Pyrenochaeta romeroi has not been reported in literature (PubMed, Medline). We report an interesting case of P. romeroi causing chronic endophthalmitis in an immunocompetent lady. Methods: Retrospective interventional case report. A 25-year-old immunocompetent lady presented with pain and redness in the left eye of 1-month duration. Her best-corrected visual acuity was 6/6 and 6/18 in the right and the left eyes, respectively. Slit-lamp examination of the left eye showed a corneal stromal scar, fibrinlike material in the anterior chamber, few retrolental cells, and normal fundus examination. Results: Aqueous taps on two occasions were negative for bacteria and fungi on routine smear, culture, and nested polymerase chain reaction. As inflammation recurred despite intravitreal voriconazole and amikacin injections, a lensectomy with vitrectomy was done. During vitrectomy, dense flocculent material was seen in the pars plana with only scleral indentation. The flocculent material grew a rare filamentous fungus called P. romeroi. The left eye underwent retinal detachment surgery with silicone oil insertion for a giant retinal tear at 2 months of follow-up. At 6 months of follow-up, her vision in the left eye was stable at 6/24 (Snellen) with no ocular inflammation. Conclusion: P. romeroi may need to be added in the list of rare fungi, which cause chronic endophthalmitis. RETINAL CASES & BRIEF REPORTS 8:197–199, 2014
From the *Department of Intraocular Inflammation and Vitreoretinal Services, Vittala International Institute of Ophthalmology and Prabha Eye Clinic and Research Center, Bangalore, India; †Department of Medical Mycology, Kasturba Medical College, Manipal, India; and ‡Department of Microbiology and Infection Control, Fortis Hospitals, Bangalore, India.
Case Report A 25-year-old immunocompetent lady was referred with a history of pain and redness in the left eye of 1-month duration. Her local ophthalmologist had noticed a white lesion in the left eye and started her on oral fluconazole of 200 mg 2 times a day, and on natamycin and moxifloxacin eye drops 6 times a day. Systemic history was significant for treatment for infertility. She had no history of diabetes mellitus or trauma. On examination, her best-corrected visual acuity was 6/6 and 6/18 in the right and left eyes, respectively. Slit-lamp examination (in the left eye) showed a corneal stromal scar, flocculent mass in the anterior chamber, a small posterior synechia at 7-o’clock position, and few retrolental cells (Figure 1A). Fundus examination was normal. An aqueous tap was negative for bacteria and fungi on smear, culture, and polymerase chain reaction. She was started on hourly voriconazole (1%) eye drops, fortified amikacin (8 mg/mL)
E
ndophthalmitis due to Pyrenochaeta romeroi has not been reported in literature (PubMed, Medline). We report an interesting case of P. romeroi causing chronic endophthalmitis in an immunocompetent lady. 197
198
RETINAL CASES & BRIEF REPORTS´ 2014 VOLUME 8 NUMBER 3
Fig. 1. A. Slit-lamp photograph of the left eye showing a corneal scar and flocculent material in the anterior chamber. B. Slit-lamp photograph of the left eye showing an increase in the flocculent material seen in the anterior chamber after a month.
Fig. 2. A. Culture plate shows olivaceous growth on the Sabouraud’s dextrose agar. B. Microphotograph showing hyaline septate hyphae with very scanty sporing bodies. The hyaline hyphae with well-developed ascus bodies.
eye drops, and oral ketoconazole of 200 mg 2 times a day. She came back 2 weeks later with an increase in pain and redness. The flocculent mass had increased and a plaque was seen on the lens (Figure 1B). This was removed along with the aqueous, and was sent for repeat smear, culture, and polymerase chain reaction for bacteria and fungi. Although the specimen was negative for bacteria and fungi, intravitreal voricanozole and intracameral injections of amikacin were given in view of the strong clinical suspicion. She came back 1 month later with a decrease in vision to 6/60, an inferonasal corneal edema, inferonasal organized flocculent material, bulky iris from 7-’o clock to 9-’o clock positions, and a creamy white membrane on lens capsule. Lensectomy with vitrectomy and intravitreal injections of voriconazole and amphotericin B were given. During vitrectomy, whitish flocculent material was seen in the pars plana on scleral indentation (see Video, None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web Site (www.retinajournal.com). Reprint requests: Kalpana Babu, DO, MRCOphth (Lon), Prabha Eye clinic & Research center, 504, 40th Cross, Jayanagar, 8th block, Bangalore 560070, India; e-mail: kalpana@ prabhaeyeclinic.com
Supplemental Digital Content 1, http://links.lww.com/ICB/A9). The undiluted vitreous including the flocculent material grew P. romeroi on culture after 5 days. The same was confirmed by two independent laboratories in the state (P.Y.P. and S.R.). Two months later, she developed total retinal detachment because of a giant retinal tear. She underwent vitrectomy with silicone oil insertion. At 6 months of follow-up, her best-corrected visual acuity was 6/24 in the left eye, and her eye was stable with no recurrences of inflammation.
Description of the Fungus The colonies were restricted, velvety-to-dark olive gray with an olivaceous reverse on Sabouraud’s dextrose agar (Figure 2A). The setae were abundant around the ostiole, dark brown, thick and smoothwalled, septate, and tapering toward the tip. The conidiophores ampulliform, hyaline, and septate emerged from all over the inner surface of the pycnidial wall were branched at the base, bearing terminal and lateral conidiogenous cells. The slide culture microscopy showing hyaline septate and
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hyphae with very scanty sporing bodies. The hyaline hyphae had ascus bodies (Figure 2B).
initial aqueous taps being negative probably because of decreased load of the fungus in the aqueous while the vitreous, obtained near the flocculent material in the pars plana, grew the fungus. With this case, P. romeroi may need to be added in the list of rare fungi causing chronic endophthalmitis.4
Discussion The coelomyceteous fungal genus Pyrenochaeta has three medically important species: Pyrenochaeta mackinnonii, Pyrenochaeta unguis-hominis, and P. romeroi.1 P. romeroi are often incriminated as agents of mycetoma,1 and to date, there are no reports of P. romeroi causing endophthalmitis in literature (Medline search). P. romeroi is a rare fungus that can cause keratitis.2,3 These fungi normally occur as a soil saprobe and on plant debris, and thus one can speculate the route of entry in our patient because the cornea was highlighted by a corneal scar, with probable initial keratitis and then evolved into endophthalmitis. The identification of a rare fungus is often not easy because it is not part of the spectrum of fungi regularly encountered in clinical samples. In our case, the challenge was in the diagnosis due to
Key words: chronic endophthalmitis, fungus, Pyrenochaeta romeroi. References 1. De Hoog GS, Guarro J, Gene J, Figueras MJ. Atlas of Clinical Fungi. 2nd ed. Utrecht, the Netherlands: Centraalbureau voor Schimmelcultures; 2000. 2. Ferrer C, Pérez-Santonja JJ, Rodríguez AE, et al. New Pyrenochaeta species causing keratitis. J Clin Microbiol 2009;47:1596–1598. 3. Gopinathan U, Garg P, Fernandes M, et al. The epidemiological features and laboratory results of fungal keratitis: a 10-year review at a referral eye care center in south India. Cornea 2002;21:555–559. 4. Chakrabarti A, Shivaprakash MR, Singh R, et al. Fungal endophthalmitis: fourteen years’ experience from a center in India. Retina 2008;28:1400–1407.
