ACTA 0 P H T H A L M 0 L O G I CA
70 (1992) 528-529
S H O R T C O M M U N I CAT1 0 N
Fluconazole in the treatment of candida albicans endophthalmitis Steen F. Urbak and Torsten Degn Department of Ophthalmology,CentralsygehusetEsbjerg,Denmark
Abstract. A 29-year-old former drug addict with candida albicans endophthalmitis determined by cultivation was treated with vitrectomy and systemic fluconazole. The infection resolved completely and the patient recovered a visual acuity of 6/6. Fluconazole was well tolerated and a high concentration was found in the vitreous cavity. Key words: candida albicans endophthalmitis zole - drug addict - antifungal treatment.
- flucona-
Case report A 29-year-old female presented with decreased vision in her left eye of four days’ duration. She was a former intravenous drug addict. The visual acuities were 616 right eye and 619 left eye. Biomicroscopy of the left eye showed a mild flare and few cells in both the anterior chamber and the anterior part of the vitreous body. Two small round white retinochoroidal foci were seen over the optic disc. There were no symptoms or signs of involvement of other organs. Topical atropine and steroid treatment, as well as systemic steroid treatment were initiated. Over the following four weeks the anterior uveitis subsided but the retinochoroidal foci remained unchanged. After five weeks a dense white vitreal opacity developed. A candida albicans infection was suspected and a subtotal vitrectomy was performed. Microscopy and cultivation showed candida albicans. 528
Blood and urin cultures, CTC and routine blood tests were normal. Oral fluconazole treatment was started with 800 mg the first day and 400 mg daily thereafter. During the following weeks the vitritis subsided and the retinochoroidal foci disappeared without scars. After six and a half weeks the concentrations of fluconazole were 15 microgradml in the vitreous cavity and 19 microgramlml in plasma. No adverse effects were found. After seven weeks of treatment and a negative cultivation from the vitreous cavity the treatment was stopped. The visual acuity was 616. The ocular fundus was normal. No relapse occurred in the following two months.
Comments Candida albicans endophthalmitis has a poor visual prognosis in most cases if left untreated, so aggressive therapy is required. For many years a m photericin B was the only drug available. Amphotericin B does, however, have many toxic effects when used systemically (Goodman & Gilman 1985). Therefore, lower dosage of amphotericin B has been used in various combinations with flucytosine and ketoconazole. However, flucytosine has a tendency to create secondary resistance and ketoconazole’s effect in disseminated candida albicans infection is questionable (Goodman & Gilman 1985).
Fluconazole is a new antifungal drug - especially active against candida albicans and cryptococcus neoformans - for both intravenous and oral administration. Pharmacokinetic studies have proven that the active unbound drug is distributed in the total body water (Brammer & Tarbit 1987), and, consequently, a good effect on disseminated infection can be expected. Studies on rabbits have shown a high concentration in the choroid and vitreous body (Savani et al. 1987). The fluconazole concentration measured in the vitreous cavity of the patient is much higher than usual MIC required for candida albicans, which is about 0.4 microgram/ml (Kristensen et al. 1990). The reported side effects in non - AIDS patients are mild i.e. nausea, abdominal discomfort and headache. The drug was well tolerated by the patient and the clinical outcome was good. Fluconazole should be considered as an alternative to other antfingal drugs in the treatment of candida albicans endophthalmitis.
27
Acta Ophthal. 70.4
References Brammer K W & Tarbit M H (1987):A review of pharmacokinetics of fluconazole in laboratory animals and man. In: Fromtling R A (ed). Recent trends in the discovery, development and evaluation of antifungal agents: 141-7.J R Prous science publ., S.A. Goodman & Gilman (1985):The Pharmacological basis of Therapeutics. Seventh edition. Macmillan Publ. Comp., New York, USA. Kristensen M B (ed) (1990):Lsegemiddelkataloget, p 234. Copenh. Savani D V, Perfect J R, Cob0 L M and Durack D T (1987): Penetration of new azole compounds into the eye and efficacy in experimental candida endophthalmitis. Antimicrob Agents Chemother 31: 6-10.
Received on October loth, 1991. Author's address:
Steen F. Urbak, Lindenborgvej 53, DK-9200 Aalborg SV, Denmark.
529
70 (1992) 528-529
S H O R T C O M M U N I CAT1 0 N
Fluconazole in the treatment of candida albicans endophthalmitis Steen F. Urbak and Torsten Degn Department of Ophthalmology,CentralsygehusetEsbjerg,Denmark
Abstract. A 29-year-old former drug addict with candida albicans endophthalmitis determined by cultivation was treated with vitrectomy and systemic fluconazole. The infection resolved completely and the patient recovered a visual acuity of 6/6. Fluconazole was well tolerated and a high concentration was found in the vitreous cavity. Key words: candida albicans endophthalmitis zole - drug addict - antifungal treatment.
- flucona-
Case report A 29-year-old female presented with decreased vision in her left eye of four days’ duration. She was a former intravenous drug addict. The visual acuities were 616 right eye and 619 left eye. Biomicroscopy of the left eye showed a mild flare and few cells in both the anterior chamber and the anterior part of the vitreous body. Two small round white retinochoroidal foci were seen over the optic disc. There were no symptoms or signs of involvement of other organs. Topical atropine and steroid treatment, as well as systemic steroid treatment were initiated. Over the following four weeks the anterior uveitis subsided but the retinochoroidal foci remained unchanged. After five weeks a dense white vitreal opacity developed. A candida albicans infection was suspected and a subtotal vitrectomy was performed. Microscopy and cultivation showed candida albicans. 528
Blood and urin cultures, CTC and routine blood tests were normal. Oral fluconazole treatment was started with 800 mg the first day and 400 mg daily thereafter. During the following weeks the vitritis subsided and the retinochoroidal foci disappeared without scars. After six and a half weeks the concentrations of fluconazole were 15 microgradml in the vitreous cavity and 19 microgramlml in plasma. No adverse effects were found. After seven weeks of treatment and a negative cultivation from the vitreous cavity the treatment was stopped. The visual acuity was 616. The ocular fundus was normal. No relapse occurred in the following two months.
Comments Candida albicans endophthalmitis has a poor visual prognosis in most cases if left untreated, so aggressive therapy is required. For many years a m photericin B was the only drug available. Amphotericin B does, however, have many toxic effects when used systemically (Goodman & Gilman 1985). Therefore, lower dosage of amphotericin B has been used in various combinations with flucytosine and ketoconazole. However, flucytosine has a tendency to create secondary resistance and ketoconazole’s effect in disseminated candida albicans infection is questionable (Goodman & Gilman 1985).
Fluconazole is a new antifungal drug - especially active against candida albicans and cryptococcus neoformans - for both intravenous and oral administration. Pharmacokinetic studies have proven that the active unbound drug is distributed in the total body water (Brammer & Tarbit 1987), and, consequently, a good effect on disseminated infection can be expected. Studies on rabbits have shown a high concentration in the choroid and vitreous body (Savani et al. 1987). The fluconazole concentration measured in the vitreous cavity of the patient is much higher than usual MIC required for candida albicans, which is about 0.4 microgram/ml (Kristensen et al. 1990). The reported side effects in non - AIDS patients are mild i.e. nausea, abdominal discomfort and headache. The drug was well tolerated by the patient and the clinical outcome was good. Fluconazole should be considered as an alternative to other antfingal drugs in the treatment of candida albicans endophthalmitis.
27
Acta Ophthal. 70.4
References Brammer K W & Tarbit M H (1987):A review of pharmacokinetics of fluconazole in laboratory animals and man. In: Fromtling R A (ed). Recent trends in the discovery, development and evaluation of antifungal agents: 141-7.J R Prous science publ., S.A. Goodman & Gilman (1985):The Pharmacological basis of Therapeutics. Seventh edition. Macmillan Publ. Comp., New York, USA. Kristensen M B (ed) (1990):Lsegemiddelkataloget, p 234. Copenh. Savani D V, Perfect J R, Cob0 L M and Durack D T (1987): Penetration of new azole compounds into the eye and efficacy in experimental candida endophthalmitis. Antimicrob Agents Chemother 31: 6-10.
Received on October loth, 1991. Author's address:
Steen F. Urbak, Lindenborgvej 53, DK-9200 Aalborg SV, Denmark.
529
