ABSTRACT
A 61-year-old woman presented to our clinic with complaints of decreased visual acuity, pain, and redness in her left eye. Best corrected visual acuity (BCVA) was 20/20 in the right eye and counting fingers at 3 meters in the left eye. On slit-lamp examination, 1+ cells were detected in the anterior chamber. Fundus examination revealed 1+ haze in the vitreous and multiple creamy-whitish lesions in the retina and vitreous. Her history included a diagnosis of coronavirus disease 2019 (COVID-19) one month earlier, for which she was hospitalized in the intensive care unit for 20 days and received systemic corticosteroid treatment. Vitreous culture yielded Candida albicans. The patient’s nasopharyngeal swab sample was positive for COVID-19 by reverse transcription polymerase chain reaction test. BCVA was improved to 20/40 after amphotericin therapy (via intravitreal injection and intravenous routes), and the vitritis and chorioretinitis lesion regressed after 2 weeks of treatment. Two weeks later, intravenous amphotericin was discontinued and oral fluconazole treatment was started at a dose of 400 mg/day. At 3-month follow-up, her BCVA was 20/25 and no inflammatory reaction was observed in the anterior chamber and vitreous.
Introduction
Endogenous fungal endophthalmitis is a severe ocular inflammation that causes decreased visual acuity.1 Candida albicans is the most common cause of endogenous fungal endophthalmitis, which is associated with predisposing risk factors such as an indwelling catheter, intravenous drug use, immunodeficiency, recent hospitalization, and use of corticosteroids or noncorticosteroid immunosuppressive agents.2
Coronavirus disease 2019 (COVID-19) is a global epidemic caused by a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]).3 Herein, we aim to report a case of Candida albicans endogenous endophthalmitis in a patient who required intensive care admission and systemic steroid therapy due to COVID-19 infection. To the best of our knowledge, this is the first description of a case of endogenous fungal endophthalmitis that may be relevant to the current treatment of COVID-19 infection.
Discussion
Endogenous fungal endophthalmitis would be expected in an immunosuppressed patient with risk factors such as chronic immune-compromising disease, intravenous catheters, use of broad-spectrum antibiotics, immunosuppressive agents, or steroids, and diabetes mellitus.1,4 As COVID-19 is a new disease, there is still limited evidence about it and the outcomes of treatment.5 Hospitalization and systemic steroid use may be required during the treatment and management of COVID-19.6 Presented here is a case of endogenous fungal endophthalmitis in a patient who required intensive care admission and systemic steroid use for the treatment of COVID-19.
Endogenous fungal endophthalmitis generally begins with choroidal spread and eventually invades the vitreous. In candidemia, the incidence of chorioretinitis is 11%, while that of endophthalmitis is only 1.6%.7 It progresses slowly, some cases are clinically silent at the early stage, and symptoms usually increase after notable vitritis. Some patients develop subretinal abscess, which generally has a poor visual prognosis. Subretinal abscess is often associated with mold rather than yeast endophthalmitis.8
There is still controversy regarding the ophthalmological effects of SARS-CoV-2 and whether transmission can occur via ocular tissues (tears). In the studies and case reports in the literature, SARS-CoV-2 was detected in ocular samples in a very small proportion of patients who were positive for COVID-19.9 It was also reported that SARS-CoV-2 has a lesser tropism for ocular tissue than the respiratory tract.10 Gupta et al.11 reported a case of atypical acute retinal necrosis in a COVID-19-positive immunosuppressed patient, but PCR test of a vitreous specimen was negative for SARS-CoV-2. Furthermore, in-vivo animal experiments on this subject have shown that coronaviruses can increase blood-retinal barrier destruction.5,12 Perhaps the fact that the patient was positive for COVID-19 in our case caused a breakdown of the blood-retinal barrier, facilitating the development of endogenous fungal endophthalmitis.
The pandemic has spread rapidly, and it is important to report cases associated with COVID-19. Further studies may show how the SARS-CoV-2 virus and treatment of COVID-19 interact with ocular tissue. The treatment of COVID-19 may lead to other opportunistic infections for reasons such as hospitalization, intravenous drug administration, and broad-spectrum antibiotic and systemic steroid use. We recommend that endogenous endophthalmitis be kept in mind in patients who present with complaints of decreased visual acuity and have a history of systemic steroid therapy and hospitalization for COVID-19.
