Recurrent endogenous candidal endophthalmitis in a premature infant

The Role of Vitrectomy in the Management of Fungal Endophthalmitis

Fungal endophthalmitis is an important cause of vision loss worldwide with a large body of literature describing the treatment of the disease. The evidence supporting the use of pars plana vitrectomy in the management of fungal endophthalmitis is largely comprised of case reports and case series and demonstrates the important role of vitrectomy surgery. Vitrectomy can improve the likelihood of establishing the diagnosis, enhance the treatment of infection by removing fungal elements in the vitreous, aid in the removal of other inoculated intraocular structures, and is an important tool in the management of vision-threatening post-infectious sequelae like retinal detachment and epiretinal membrane.

[Endogenous Candida lens abscess in a premature infant]

BACKGROUND

This case report describes an extremely rare Candida lens abscess in a premature infant (gestational age 24 weeks at birth).

CASE REPORT

After birth the infant suffered from Candida sepsis which was successfully treated with an antifungal medication. The patient was referred at the age of 6 months because of greyish alterations in the pupils but an absence of other symptoms. The examination with the patient under general anesthesia revealed a grey pupillary membrane and behind it a whitish swollen lens. A lensectomy was performed. The vitreous body was inconspicuous. Candida albicans was identified microbiologically.

CONCLUSIONS

In preterm infants dissemination of pathogens into the lens through the vascular coat of the lens is possible, which after regression of the coat is no longer accessible to systemic treatment and may thus be manifested as delayed abscess formation.

Treatment outcomes and clinicomicrobiological characteristics of a protocol-based approach for neonatal endogenous endophthalmitis

PURPOSE

To describe the outcomes and clinicomicrobiological profile of 11 years of a protocol-based management in neonatal endogenous endophthalmitis.

METHODS

This was a retrospective interventional study of endogenous endophthalmitis in 31 eyes of 26 neonates. The protocol for active infection included systemic antimicrobials, vitreous and/or aqueous tap, and intravitreal antimicrobials under topical or general anesthesia along with core vitrectomy in selected cases. Blood, urine, umbilicus, aqueous, and vitreous samples underwent microbiological evaluation. Retinopathy of prematurity screening and treatment were done when indicated. Primary outcome was anatomic status assessed by comprehensive eye examination and by fundus photography whenever possible.

RESULTS

Twenty-one of 26 babies (81%) were preterm. Two types of presentations included those with a fulminant appearance (24 eyes) and those with focal retinitis detected during routine screening (7 eyes). Vitreous culture was positive in 12/20 eyes (60%). Pseudomonas aeruginosa (8) was the most common isolate. Incorrect initial diagnosis was common. Treatment included intravitreal injections in 26 eyes, 10 of which also underwent vitrectomy. Twenty-four of the 26 patients (92%) received parenteral antimicrobials and 17 had evidence of systemic infection. All eyes with a fulminant presentation developed phthisis, while all focal fungal cases were salvaged.

CONCLUSIONS

Neonatal endogenous endophthalmitis has 2 distinct presentations. Focal retinal infections have good visual and anatomical outcomes while fulminant nosocomial cases do poorly. Management under topical anesthesia can be an alternative strategy for sick babies that cannot undergo surgery under general anesthesia due to systemic morbidity. Awareness about early diagnostic signs may help early referral.

Bilateral Candida endophthalmitis in a premature infant

Endogenous infantile Candida endophthalmitis is a rare but potentially devastating condition resulting from sequestration of the fungus within the lens after systemic infection. We report the case of a 20-week-old girl with a history of Candida sepsis who presented with bilateral Candida albicans endophthalmitis 15 weeks after completing a 6-week course of intravenous antifungal therapy. Prompt vitrectomy resulted in salvage of the right eye, although a total retinal detachment occurred. Cataract extraction and administration of intravenous and intravitreal amphotericin B preserved vision in the left eye.

Neonatal endogenous endophthalmitis: a report of six cases

Endogenous endophthalmitis is a rare but potentially blinding complication of neonatal sepsis. Early diagnosis and aggressive treatment are essential to avoid vision loss. Therapeutic options include systemic and intravitreal antibiotics, as well as vitrectomy in selected cases. We report a series of 6 premature very low birth weight neonates who developed endogenous endophthalmitis in our NICU over the past 3 years. Endophthalmitis was part of early-onset sepsis in 2 newborns, both of whom died, and late-onset sepsis in 4 newborns, of which 1 infant died. None of the neonates had any history of previous trauma or intervention to the eye. Maternal screening for congenital infections, including HIV, was negative in all. Causative organisms included Klebsiella pneumoniae (2 cases), Pseudomonas aeruginosa (2 cases), Methicillin-resistant Staphylococcus aureus (1 case), and Candida albicans (1 case). All bacterial isolates showed resistance to first-line antibiotics. Of the 3 survivors, 2 infants had normal vision in the affected eye, and 1 developed phthisis bulbi after corneal perforation and required enucleation. This report draws attention to the emergence of endophthalmitis as a complication of neonatal sepsis in places where, although survival of very low birth weight newborns has increased significantly due to improved care, the burden of infection continues to be high. We emphasize the importance of daily examination of eyes as a part of routine clinical care in septic newborns for early diagnosis of endophthalmitis and prompt intervention in consultation with an ophthalmologist to optimize the outcome.

Candida species lens abscesses in infants with a history of neonatal Candida sepsis

We report 3 patients who were delivered prematurely and who developed a lens opacity with signs of ocular inflammation at a postgestational age of 10-52 weeks. All patients had been treated for Candida sepsis as neonates. Each patient underwent lensectomy and anterior vitrectomy. In 2 infants Candida albicans was cultured from the lens/anterior chamber membrane; in 1 Candida parapsilosis was cultured from a lens aspirate. Despite eradication of the fungal infection, outcomes were poor: 2 eyes developed glaucoma, and 1 developed a retinal detachment with subsequent phthisis.

Bibliographical investigation (domestic and overseas) on the treatment of endogenous Candida endophthalmitis over an 11-year period

A bibliographic search was conducted of cases of Candida endophthalmitis reported in Japan and overseas between 2000 and 2011, in the Japana Centra Revuo Medicina Website of Japan Medical Abstracts Society (domestic reports) and MEDLINE (overseas reports). The investigation yielded 42 reports in domestic journals (49 cases ; hereinafter referred to as domestic cases) and 39 reports in journals published overseas (46 cases ; hereinafter referred to as overseas cases). The isolation rate of Candida albicans in the domestic cases was 65.3%, and that in the overseas cases was 71.7%. The initial treatment for the Candida endophthalmitis was fluconazole (FLCZ) therapy in 51.0% of the domestic cases and 38.1% of the overseas cases. Domestic reports suggested the effectiveness of FLCZ therapy for stage II cases, and of vitrectomy for stage III and IV cases. Reports from overseas, on the other hand, suggested the effectiveness of amphotericin B (AMPH-B) or voriconazole (VRCZ) therapy for stage II cases, and of vitrectomy for stage III and IV cases.

Recurrent Enterococcus faecalis endophthalmitis after phacoemulsification

We present the first reported case of late recurrence of postoperative Enterococcus faecalis endophthalmitis after cataract surgery in a 45-year-old diabetic man. Culture-positive E faecalis endophthalmitis was diagnosed 2 days after uneventful phacoemulsification. Early vitrectomy with intravitreal and subconjunctival vancomycin and amikacin and topical vancomycin resulted in apparently complete clinical resolution after 4 months and a best corrected visual acuity of 20/25. Recurrent endophthalmitis with hypopyon occurred 7 months postoperatively and resolved with intravitreal vancomycin and topical prednisolone acetate 1%. However, the patient had a similar relapse at 9 months that resulted in deterioration of visual acuity to no light perception despite a repeat vitrectomy, intraocular lens explantation, capsular bag removal, and intravitreal antibiotics. The late recurrences could have been the result of persistent sequestration of the organism in the capsular bag.

Low yield of ancillary diagnostic studies in neonates infected with Candida

BACKGROUND

Fungal infection can be a significant complication for the critically ill neonate. However, the usefulness of extensive radiologic and ophthalmologic investigations in this population has not been thoroughly elucidated.

OBJECTIVE

To report the incidence of organ fungal involvement diagnosed by ancillary testing (echocardiogram, ophthalmologic examination, brain imaging, and renal ultrasound (RUS)) among neonatal intensive care unit (NICU) patients with Candida infection.

METHODS

This was a single center review of all NICU patients with Candida-positive cultures of blood, urine, peritoneal fluid, endotracheal tube aspirate, or cerebrospinal fluid from January 1, 1997 to June 1 2002. Data regarding the number of positive cultures, species isolated, and presence of specific risk factors and clinical symptoms were recorded for each case, as well as occurrence, timing and results of ancillary testing.

RESULTS

In all, 66 patients had at least one positive culture for Candida. The majority (71%) were <1500 g at birth, and mean gestational age was 29.5+/-5.6 weeks. Echocardiograms were obtained in 54/66 (82%), and ophthalmology examinations were obtained in 36/66 (55%); none of these was consistent with fungal involvement. Brain imaging was performed in 50/66 (76%), only one of which was positive, in a patient with 16 positive blood cultures for Candida albicans. RUS were performed in 58/66 (88%) of patients, with concerning findings for fungal involvement in seven of the studies. RUS findings alone did not appear to consistently influence the length of therapy.

CONCLUSIONS

Ancillary evaluations to investigate for fungal dissemination were undertaken frequently, but were of overall low yield. Although ancillary testing may be of limited additional value in centers with a low threshold for suspecting fungal infections and an aggressive approach to therapy, potentially important findings, which could impact management, may occur.

Neonatal candidiasis: ophthalmologic infection

Endophthalmitis results from hematogenous seeding of the eye in preterm infants with candidiasis. Early systemic therapy decreases the frequency of eye involvement, now only about 6% in infants with systemic candidiasis. Eye disease can occur on the first day, but is more likely with prolonged candidemia. Candida albicans and C tropicalis predominate in newborns. Indirect ophthalmoscopy will identify the characteristic unilateral or bilateral, yellow-white, fluffy, retinal or vitreal balls with frequent hemorrhage or inflammatory vitreous haze. Systemic antifungal therapy alone usually results in good visual outcome, but unresponsive or recurrent lesions are reported. Lens abscesses presenting as cataracts may be seeded before regression of the tunica vasculosa lentis, leaving an infection nidus in a subsequently avascular structure that is poorly reached by antifungal drugs. Lensectomy may be required to clear the visual field and the infection. Candidemia is also implicated in progression of retinopathy of prematurity to stage 3 or beyond, possibly due to induction of cytokines or angiogenic factors.

Neonatal candidemia and end-organ damage: a critical appraisal of the literature using meta-analytic techniques

OBJECTIVE

Neonatal candidemia is an increasing cause of infant morbidity and mortality. We evaluated the current medical literature in an effort to critique the literature and to document the reported prevalences of end-organ damage after neonatal candidemia.

METHODS

We analyzed all peer-reviewed articles of neonatal candidemia published in the English language; inclusion criteria included a cohort limited to all neonatal intensive care unit admissions or all episodes of candidemia in neonates. Articles that also incorporated older patients, did not define a numerator and a denominator for at least 1 form of end-organ damage, included patients from other reports, or did not include all episodes of candidemia in the source population were excluded from the analysis.

RESULTS

Thirty-four articles reported episodes of candidemia and mortality; 21 articles reported prevalence for at least 1 form of end-organ damage. Only 4 (19%) of 21 articles reported prevalence for >4 forms of end-organ damage from the following list: endophthalmitis, meningitis, brain parenchyma invasion, endocarditis, renal abscesses, positive cultures from other normally sterile body fluids, or hepatosplenic abscesses. The median reported prevalence of endophthalmitis was 3% (interquartile range [IQR]: 0%-17%), of meningitis was 15% (IQR: 3%-23%), of brain abscess or ventriculitis was 4% (IQR: 3%-21%), of endocarditis was 5% (IQR: 0%-13%), of positive renal ultrasound was 5% (IQR: 0%-14%), and of positive urine culture was 61% (IQR: 40%-76%). The medical literature concerning end-organ evaluation after episodes of neonatal candidemia is heterogeneous and consists largely of single-center retrospective studies. Year that the data were collected and prevalence of neonates infected with Candida albicans were associated with observed heterogeneity.

CONCLUSIONS

Given the heterogeneity of the medical literature, precise estimates of the frequencies of end-organ damage are not possible and a prospective multicenter trial is warranted, but the data from the published literature suggest that the prevalence of neonates with end-organ damage not only is greater than 0 but also is high enough that until such a prospective trial is completed, end-organ studies should be considered before the conclusion of antifungal therapy.

Ocular involvement in children with candidemia

PURPOSE

To evaluate ocular findings in hospitalized children with systemic Candida species infection.

DESIGN

Retrospective review of inpatient hospital consultations.

METHOD

Inpatient hospital consultations performed by a pediatric ophthalmology service over a 30-month period were reviewed.

RESULTS

Of 600 consultations performed by the service, 30 were to rule out ocular findings in patients with suspected or known candida infection. No patients had ocular findings consistent with endophthalmitis or chorioretinitis. One patient had nonspecific findings of multisystem organ failure, and one had vascular findings secondary to elevated pulmonary venous pressures.

CONCLUSIONS

In contrast to the results of studies performed 10 to 15 years ago, ocular involvement is highly unusual in children with candidemia, but such consultations account for a substantial workload. Further attention to risk factors associated with ocular infection is warranted.

Candida (amphotericin-sensitive) lens abscess associated with decreasing arterial blood flow in a very low birth weight preterm infant

In this report, we review the case of a candidal lens abscess in a premature infant girl who was 28 weeks' gestational age at birth. The culture obtained from the lens abscess grew Candida albicans sensitive to amphotericin B but resistant to flucytosine. This case is unique in that the infant developed a fungal lens cataract at 34 weeks' postconceptional age during the last week of a 30-day course of amphotericin B. The embryonic hyaloid artery system, which perfuses the developing lens, regresses between 29 and 32 weeks of gestation; thus, the mechanism for an infection of the lens may be inoculation of the lens by Candida before hyaloid artery system regression, followed by developmental loss of this blood supply, which makes the lens inaccessible to antimicrobial penetration. Candidal endophthalmitis with lens abscess is an uncommon morbidity that requires prompt recognition and surgical intervention for effective management.

Iris nodules associated with infectious uveitis

BACKGROUND/AIM

Iris nodules are an uncommon clinical sign in uveitis. The diseases most commonly associated with iris nodules and uveitis include sarcoidosis, Vogt-Koyanagi-Harada syndrome, multiple sclerosis, Fuchs' heterochromic iridocyclitis, and metastatic infection. While many of these diseases may be appropriately treated with immunosuppressive medication, the management of infectious uveitis is antimicrobial therapy. Inappropriate immunosuppressive therapy may result in a poor outcome for the patient with an infection. Consequently, cases of uveitis with iris nodules were reviewed to identify clinical features that may help differentiate infection from non-infectious inflammation.

METHODS

The clinical database of 1353 consecutive patients evaluated at a tertiary care referral based North American uveitis clinic were retrospectively reviewed to identify cases of infectious uveitis with iris nodules. A Medline search was performed to identify additional cases. From these cases information regarding clinical presentation, diagnosis, treatment, and outcome were collected.

RESULTS

Three cases (three eyes) were identified from the authors' own records of infectious uveitis with iris nodules. An additional 25 cases of infectious uveitis with iris nodules were identified in 22 published reports. Analysis of the authors' cases and these reports showed that infectious uveitis with iris nodules was specifically characterised by some or all of the following: (1) creamy, soft appearance to the nodule(s), (2) unilateral disease, (3) persistence or growth of the nodule(s) despite corticosteroid therapy, (4) marked inflammatory response in the anterior chamber and/or vitreous humour, and/or (5) history suggesting a potential source of septic emboli.

CONCLUSION

Certain features of the clinical history and examination are useful in the diagnosis of metastatic infection in patients presenting with uveitis and iris nodules.