Fusarium endophthalmitis after intravitreal bevacuzimab injection

A.M.L. Oude Lashof, F.H. Van Tiel, E.C. La Heij

Author address: 

Maastricht University Medical Center, MAASTRICHT, The Netherlands

Abstract: 

A 75 year old woman with a history of diabetes and diabetic retinopathy was seen at the outpatient eye clinic for worsening of her age-related macular degeneration. She was treated with intravitreal administration of bevacizumab (1.25 mg) and prednisolone (5mg). The first injection in her left eye was without any complications, therefore a second injection in this eye was performed one month later. Unfortunately, 5 days after this second injection, she experienced pain in her left eye and visited the eye clinic. She presented with a red left eye, a decreased visual acuity of Hand Movements or 1/300, and high intraocular pressure (30 mmHg). In addition, a hypopyon and fibrin was seen in the anterior chamber. Fundus examination was impossible due to a dense vitreous haze. There were no signs or symptoms of keratitis or systemic inflammation. An intravitreal biopsy was performed and Gram staining showed leukocytosis without bacteria. Treatment according to the endophthalmitis protocol was started with intravitreal, local and intravenous vancomycin and ceftazidime. Five days after the puncture Fusarium spp was cultured and treatment was changed in local amphotericin B and intravenous voriconazole, a loading dose of 400 mg twice a day, followed by 300 mg twice daily. In addition, a complete pars plana vitrectomy with lense extraction was performed, in an attempt to evacuate as much pus as possible. The retina already showed severe ischemia, with necrosis and vessel occlusions. Amphotericin B was left intravitreally. Unfortunately, we were not able to perform a species differentiation, but the antifungal susceptibility test showed MIC voriconazole 4 mg/l, amphotericine B 2 mg/l, posaconazole 2 mg/l, caspofungin 16 mg/l. Therefore, we decided to treat her with local administration of amphotericine B and systemic voriconazole for 3 months. Despite this long term treatment, the vision of her left eye showed no improvement. This is the first report of Fusarium endophthalmitis associated with intravitreally administered bevacizumab and prednisolone. Fusarium endophthalmitis may occur in immunocompetent individuals after ocular surgery, such as cataract extraction, or as a complication of advanced keratitis. In severely immunocompromised patients haematogenous spread may result in disseminated fusariosis. In our case, Fusarium endophthalmitis developed in a locally immunocompromised eye, after intravitreal injection of bevacizumab and prednisolone. Bevacizumab, a recombinant humanized monoclonal IgG1 antibody, binds to and inhibits the biologic activity of vascular endothelial growth factor. This leads to less inflammation and improvement of vision by inhibition of new vessel formation and reduction of macular edema. However, suppression of the local inflammatory response by bevacizumab and prednisolone may also result in a diminished response to infection. This local immunocompromised state facilitated a full-blown endophthalmitis. The treatment of Fusarium endophthalmitis is difficult: the penetration of iv amphotericin B formulations in the vitreous is lacking. Besides, many Fusarium isolates are voriconazole resistant, although breakpoints for filamentous fungi have not been established. Combination of pars plana vitrectomy and therapy of local amphotericin B and systemic voriconazole could not improve her vision.
2009

abstract No: 

P167

Full conference title: 

4th Trends in Medical Mycology
    • TIMM 4th (2012)