Background: Endogenous Aspergillus fumigatus endophthalmitis with poor visual prognosis in diabetes mellitus patients with COPD has been reported. A 59-year-old diabetic man with a history of COPD and obesity presented to the ER with shortness of breath from congestive heart failure. He was treated with systemic steroid and moxifloxacin. A week later, he became febrile with a new bilateral patchy infiltrates on the chest X-ray, developed oral thrush, and culture confirmed herpes simplex pharyngitis. In the ICU, he was treated with piperacillin-tazobactam, acyclovir, and IV fluconazole (FL). Subsequently, the patient pulmonary status deteriorated and experienced decreased vision in the left eye with fluffy infiltrates in the inferior retina and scattered retinal hemorrhages. He underwent vitrectomy with injection of intravitreal vancomycin, ceftazidime, and amphotericin B (AP) in conjunction with systemic caspofungin (CS) therapy. Methods: In addition to Calcofluor white and Gram-stains, vitreous fluid was directly inoculated into blood culture bottle, thioglycolate broth, blood agar, chocolate agar, and Sabouraud dextrose agar. Blood culture was performed in BACTEC-9240 (Becton Dickinson) system. Antifungal susceptibility of the A. fumigatus was performed by E-test (AB BIODISK, Bio-Merieux) on RPMI agar (REMEL) inoculated with 0.5 McFarland fungal suspension. Results: The Calcofluor white stain was remarkable for a few suspicious hyphal fragments but the Gram-stain was negative. Patient’s blood cultures remained negative. Because the vitreous fluid cultures grew mold which was identified as A. fumigatus his systemic CS therapy was replaced with oral voriconazole (VO). The isolate was susceptible to AP, CS, itraconazole, and VO, and resistant to FL with MIC of 0.50, 0.19, 0.75, 0.19, and ≥ 256, respectively. He received 2 additional weekly intravitreal injections of AP. Conclusions: Steroid therapy in diabetes patient with COPD may play a role in endogenous systemic aspergillosis including endophthalmitis. The patient was successfully treated with marked vision improvement by intravitreal injection of AP and systemic CS and VO therapy.
Full conference title:
110th General Meeting American Society for Microbiology
- ASM 110th (2010)