Candida lusitaniae Endophthalmitis: A Brief Literature Review with a Focus on Treatment Options

Case Presentation

The patient is a 32-year-old male with a past medical history of intravenous (IV) drug use and a recently diagnosed methicillin-resistant Staphylococcus aureus right calf abscess who presented with a two-week history of left eye pain. He denied any kind of external trauma or surgical procedures to his left eye and was not a contact lens wearer. His initial symptom was pain that worsened over time. He then developed progressive vision loss along with sensitivity to light. He reported intermittent fevers and chills since the onset of his eye pain. At the time of presentation, he was not taking any antibiotics for his right calf abscess

On arrival, his vital signs included a temperature of 99.5 degrees Fahrenheit, a heart rate of 97 beats/minute, a blood pressure of 136/77, and a respiratory rate of 18, and oxygen saturation was 98% at room temperature. His initial comprehensive metabolic exam revealed hyponatremia with a sodium level of 132 mmol/L (normal- 135–146), and the rest of the electrolyte and liver function tests were within normal limits. His complete blood count revealed anemia with a hemoglobin level of 10.9 (normal: 14–17 g/dL) and thrombocytosis with a platelet count of 459,000 (normal: 140–400 B/L), but his white blood count was within a normal range with 75% differential neutrophils. Upon initial examination through ophthalmology, he exhibited the presence of more than 20 white blood cells with 1 mm hypopyon in the anterior chamber and moderate-to-severe vitreous opacities in B scan ultrasonography but no evidence of retinal detachment. The examination of his right eye failed to
reveal any abnormalities. These findings were highly suspicious for endogenous endophthalmitis in a patient actively using IV drugs. Ophthalmology obtained intravitreal cultures and provided local treatment with 0.1 mL intravitreal vancomycin, 0.1 mL ceftazidime and 0.1 mL voriconazole.

Given the suspicion for a systemic infection, two sets of blood cultures were drawn, and he was then started on broad-spectrum antibiotics, including vancomycin 1 g Q12H and piperacillin/tazobactam 3.375 g Q8H. He was also screened for HIV, Hepatitis B and C, given his IV drug abuse history. We also ordered a transthoracic echocardiogram (TTE) that showed no evidence of vegetations; however, he did have evidence of mildly thickened aortic valve leaflets. An aerobic bottle from one of the two sets of blood cultures drawn on admission was positive with a time to positivity (TTP) of 38 h using our BD BACTEC FX instrument. Gram stain (Figure 1) demonstrated yeast. Vancomycin and Piperacillin/Tazobactam were stopped, and he was started empirically on Anidulafungin pending further work up and identification of the yeast. This yeast was eventually identified as Candida lusitaniae through matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF). Vitreous fluid cultures and repeat blood cultures remained negative. Given the prolonged duration of the symptoms and thickened aortic valve leaflets in the TTE along with the high-risk history of our patient, we opted for a transesophageal echocardiogram (TEE), which was negative for vegetations. His vision improved over time, and there was resolution of hypopyon upon repeat ophthalmologic examination with stable vitreous opacities. He was eventually discharged on 400 mg oral fluconazole daily for a total of 4 weeks based on the susceptibility data provided by our microbiology lab (Table 1). He was given instructions to follow up with us and ophthalmology, but unfortunately was lost to follow up. However, he re-presented to our institution 3 months later with symptoms of opioid withdrawal and did not have any visual complaints at that time.

Figure 1: Gram stain from our patient.

Table 1: Candida lusitaniae MIC values for our patient.

Discussion

We report a case of endogenous endophthalmitis secondary to C. lusitaniae fungemia. He was re-admitted to our center 3 months later for a different problem and did not report any ocular complaints at that time. Yamamoto and colleagues described a case of a 69-year-old patient on immunomodulators with bilateral endophthalmitis due to C. lusitaniae fungemia successfully treated with 42 days of systemic antifungal therapy without intravitreal antibiotic injections, the majority of which consisted of systemic fluconazole and is the only other case report describing endophthalmitis due to C. lusitaniae to the best of our knowledge [6].

Author Contributions

H.S.: Wrote majority of the case report and contributed the most to literature search; D.W.: Proof read the case report and made necessary changes; C.V.: Reviewed microbiological data and provided references for the treatment part of the case; J.H.: Wrote the abstract of the case report. All authors have read and agreed to the published version of the manuscript.

Funding

The case report has no external funding.

Conflicts of Interest