ABSTRACT
Endogenous endophthalmitis is a serious sight-threatening ocular emergency that usually occurs in patients with serious underlying risk factors. In this report, we describe a case of endogenous Candida endophthalmitis following trans-urethral lithotripsy in an immunocompetent woman. In our case, the retinal lesion regressed completely and vision was restored. We discuss diagnostic procedures and management strategies in this article.
Introduction
Endogenous endophthalmitis is an ocular emergency that can lead to catastrophic ophthalmic complications. Endogenous fungal endophthalmitis (EFE) results from dissemination of fungal organisms from infected organs to the ocular vascular network following fungus seeding in the choroid and retina.1,2,3 The organisms responsible for EFE are Candida, Aspergillus, and Coccidious.2,3 Trans-urethral lithotripsy (TUL) is a minimally invasive endoscopic procedure performed using a rigid or flexible uretroscope.4 Here, we report a rare case of endogenous Candida endophthalmitis (ECE) after TUL in a healthy woman.
Discussion
ECE is a devastating ocular infection. Predisposing conditions include long-term systemic antibiotic usage, hospitalization, indwelling catheters, candiduria, major gastrointestinal intervention, prolonged intravenous line, hemodialysis, liver cirrhosis, intravenous drug abuser, immunomodulatory therapy, chemotherapy, diabetes mellitus, hematopoietic, organ transplantation, abortion, and HIV.1,2,3,5
Fungi may enter bloodstream during urinary tract interventions due to mechanical abrasion and epithelial trauma, leading to candidemia and intraocular candidiasis. Some reported infectious complications after urinary tract procedures include urinary tract infection, urosepsis and candidemia, perinephric and renal abscesses, urinoma, Klebsiella endophthalmitis, and retroperitoneal abscess.6 We found 5 case reports of ECE following urinary tract lithotripsy in our literature review.7,8,9,10,11 In 3 cases, ECE occurred after ESWL and uretroscopy for double-J stent placement.7,8,9 In one case, ECE occurred following TUL and ureteral stent placement10 and in the last case report it occurred after decompressive nephrostomy.11 In 4 cases, preoperative urine culture was positive for C. albicans and the patients suffered from debilitating diseases (liver cirrhosis, rheumatic arthritis, alcoholic liver disease, or diabetes mellitus).8,9,10,11 In our case, ECE occurred in an immunocompetent woman after TUL double-J stent placement while pre- and postoperative urine and blood cultures were negative and there were no underlying risk factors.
The diagnosis of ECE is difficult due to its various ocular manifestations and low positive culture rate, especially in cases with minimal vitreous involvement. The condition does not only occur in patients with underlying risk factors, but also in healthy individuals. Thus, there is the risk of misdiagnosis, leading to delay in initiating appropriate treatment. For more accurate diagnosis, vitreous tap sampling or diagnostic vitrectomy is recommended in suspicious cases, since diagnostic vitrectomy shows a higher positive culture rate and intravitreal injection can be performed simultaneously.1,2,3,5,8 Moreover, RT-PCR is more sensitive than culture, but more expensive and might be unavailable.1,2,3 In this case report, RT-PCR analysis of the vitreous sample was positive for C. albicans, but vitreous smear and culture were negative.
Timely diagnosis and rapid antifungal therapy are associated with better visual outcomes.2,3 ECE treatment depends on the severity of inflammation and the patient’s visual acuity. Appropriate treatment in patients with isolated choroidoretinitis is systemic medication with good intravitreal penetration, such as voriconazole and fluconazole. When a patient presents with choroidoretinitis and mild to moderate vitritis, systemic therapy accompanied by intravitreal injection of amphotericin-B or voriconazole is appropriate. In sight-threatening conditions and severe vitritis, pars plana vitrectomy with intravitreal medication during vitrectomy and systemic medication are recommended.1,2,3 Although intravitreal injection of amphotericin-B is very effective, intravenous injection of amphotericin-B is not recommended due to poor intravitreal penetration and systemic complications such as nephrotoxicity.1 In our case, swift diagnosis and appropriate antifungal treatment (systemic fluconazole + intravitreal amphotericin-B) led to good visual outcome.
ECE after urinary tract interventions is a rare but vision-threatening infection that may occur in immunocompetent individuals. Early detection and timely treatment can lead to better visual prognosis.
