A rare case of Aspergillus terreus endogenous endophthalmitis in a patient of acute lymphoid leukemia with good clinical outcome

Sir,

Endogenous fungal endophthalmitis is associated with immunocompromised states, indwelling catheters, chemotherapy, intravenous drug abuse, and organ transplantation.¹ The most common causative organism is Candida albicans.¹ Among the Aspergillus species A. flavus, A. fumigatus, or A. niger are common. Aspergillus terreus is very rare.^{2, 3, 4} The outcomes in A. terreus endophthalmitis are generally poor.^{2, 3} We report a case of A. terreus endogenous endophthalmitis in a patient with acute lymphoid leukemia with good response to treatment.

Case report

A 33-year-old female presented with decreased vision in her left eye since 6 days. She is a patient of acute lymphoid leukemia and on chemotherapy. Six weeks ago, she had treatment for Candida septicemia. Her latest bone marrow and peripheral smear examination revealed morphological remission. The patient had cervical lymphadenopathy and an indwelling femoral vein catheter. The examination of the right eye was normal. The vision in right eye was 6/6 and in the left eye was 6/24. The left eye showed whitish exudates in the macula area with overlying vitreous exudation and 1+ vitreous cells (Figure 1a).

Figure 1.

(a) Left eye color fundus photograph showing whitish exudates over the macula area with overlying vitreous exudation. (b) Left eye color fundus photograph at 14th post treatment day showing resolved vitreous exudates and macular edema. (c) Potato dextrose agar and blood agar showing furrowed velvelty cinnamon colored powdery growth suggestive of Aspergillus terreus. (d) Lactophenol cotton blue slide culture mount showing filamentous fungi with long conidia on segmented steria covering only the top of the vesicle of the conidiophore confirming the fungus as Aspergillus terreus.

A presumptive diagnosis of early fungal endophthalmitis was made. A posterior vitreous biopsy was taken using a single 23G port and intravitreal vancomycin, ceftazidime, and amphotericin B injections were given. The vitreous sample was positive for fungal DNA. The growth on culture (Figure 1c) and a lactophenol cotton blue culture mount showed A. terreus (Figure 1d). The patient was started on 5% natamycin eye drops eight times per day, homatropine 2% eye drops three times per day and oral ketoconazole 200 mg twice daily. The 14th day follow-up showed absence of cells in the vitreous with resolved exudates and the final visual acuity was 6/6 in her left eye (Figure 1b).

Comment

Our patient has risk factors of immunocompromised state, indwelling catheter, and chemotherapy. A. terreus endophthalmitis is a very rare form of endogenous endophthalmitis. High clinical suspicion and sample taken from the exudates in the posterior pole through single 23G port helped in isolation of the fungus. Prompt institution of antifungals resulted in good clinical outcome. Use of newer azoles like voriconazole should also be kept in mind.⁵

The authors declare no conflict of interest.