Encephalitis and Inherited HHV-6

Endogenous Fusarium Endophthalmitis inHematologic Malignancy

Short Case Series and Review of Literature

Sharad Suryakant Malavade, DNB (Ophth), MPH,*Þ Mo Mai, MD,þ Peter Pavan, MD,*Georgina Nasr, MD,§ Ramon Sandin, MD, MS,|| and John Greene, MD§||

Abstract: Patients with hematologic malignancy are in a state ofimmunocompromise either due to the disease or as result of treatment.They are at risk for opportunistic fungal infections. The usual agents im-plicated are Aspergillus and Fusarium species. Patients with infectedskin lesions are at risk of endogenous dissemination, and the eye canbe one of the potential sites of infection due to hematogenous Fusariumdissemination. We describe 3 immunocompromised patients with hemato-logic malignancy who developed endogenous fusarial endophthalmitis.

Key Words: Fusarium, endogenous endophthalmitis, hematologicmalignancy

(Infect Dis Clin Pract 2013;21: 6Y11)

Patients with hematologic malignancy under treatment are ina state of immunocompromise either due to the disease or

as result of treatment. A common complication in these patientsis fungal infection. Fusarium species have recently emerged as acommon pathogenic fungus next to Aspergillus in immunocom-promised patients. Infections due to Fusarium are a diagnosticdifficulty just like aspergillosis, with the exception that bloodcultures can aid in the diagnosis of fusarial infection in halfthe affected patients. There is no definitive treatment for fusar-iosis yet, and Fusarium exhibits varying susceptibility to vari-ous antifungal agents. Consequently, high mortality is observedin these patients. We describe 3 patients who developed dissemi-nated fusariosis with endophthalmitis over a period of 12 yearsfrom 1999 to 2010.

CASE REPORTS

Case 1A 62-year-old Hispanic man with history of primary refracto-

ry stage IIIB Hodgkin disease was admitted for high-dose chemo-therapy followed by autologous peripheral stem cell transplantationin 2000. Following admission, the patient was administered topote-can, ifosfamide, mesna, and etoposide chemotherapy per standardprotocol. Following this, the patient became neutropenic, devel-oped severe mucositis, and was put on total parenteral nutritionand patient-controlled analgesia. The patient also developed neu-tropenic fever with no known source of infection and was admin-istered neutropenic fever protocol with vancomycin and cefepime

with additional prophylactic acyclovir and fluconazole. Ten daysafter stem cell infusion, the patient developed a right-foot rednessand swelling. Sporadic papular lesions were noted on the trunkand lower extremities. He was febrile despite the antibiotics. A bi-opsy of the foot yielded Fusarium, and amphotericin B was ini-tiated. No susceptibility testing of the mold was done. The rightfoot responded very well, and the fever resolved. The patientengrafted on day 13, and his general condition improved rapidly.However, he developed a right-eye conjunctival infection thatappeared to be conjunctivitis. A computed tomogram of thesinuses did not show abnormalities. A detailed metastatic evalua-tion for fungal infection was not done. The patient gradually de-veloped blurry vision. The right eye had hand-movementvision, and the retina was poorly visualized. Vision in the lefteye was 20/100, and posterior segment evaluation revealed exu-dates and cotton wool spots. Right-eye endophthalmitis was sus-pected, and an emergency retina consult was requested. Thepatient underwent a right-eye pars plana vitrectomy with intravi-treal injection of 0.005 mg of amphotericin B in 0.1 mL and1 mg of vancomycin in 0.1 mL. Periocular injections of solutionscontaining 25 mg/mL of vancomycin, 0.5 mg/mL of amphoteri-cin B, 200 mg/mL of ceftazidime, and 8 mg/mL of dexametha-sone were administered. The vitreous biopsy grew mold (Fig. 1).The patient was administered intravenous itraconazole andamphotericin B. Topical therapy included topical vancomycin50 mg/mL, ceftazidime 50 mg/mL, amphotericin B, and nata-mycin. The patient died because of refractory leukemia and dis-seminated fusariosis while on this treatment.

Case 2A 66-year-old man with acute myeloid leukemia (AML sub-

type M2) was admitted for reinduction and chemotherapy withwhite cell count of 8.33 � 103/KL, hemoglobin of 9.2g/dL, he-matocrit of 27.8%, and platelet count of 20 � 109 platelets/L.He had an absolute neutrophil count of 3920 and 12% blasts.The patient was noted to have a purplish lesion on the right fifthtoe. He was administered cladribine, cytarabine, and granulo-cyte colony-stimulating factor per protocol. Because this thera-py could cause neutropenia, increasing the risk of fungalinfection, the patient was placed on liposomal amphotericin Band voriconazole. The patient received imatinib for 14 days.The foot lesion worsened, and imaging studies suggested possi-ble osteomyelitis. An orthopedic consultation recommendedamputation of the right fifth toe, which was done on the 20thday after admission. Cultures revealed Fusarium species as wellas Escherichia coli. No susceptibility testing was done forFusarium. The patient remained on liposomal amphotericin Buntil he developed renal insufficiency; thereafter, he was treatedwith voriconazole and meropenem. No metastatic evaluation forfungal infection was done. He underwent bone marrow aspira-tion and biopsy after 2 weeks of induction to assess responsethat showed less than 5% cellularity and less than 5% blasts

REVIEWARTICLE

6 www.infectdis.com Infectious Diseases in Clinical Practice & Volume 21, Number 1, January 2013

From the Departments of *Ophthalmology and †Global Health, Universityof South Florida, Tampa, FL; ‡Ross University School of Medicine, Common-wealth of Dominica, West Indies; §Department of Infectious Diseases, Uni-versity of South Florida; and ||Moffitt Cancer Center, Tampa, FL.Correspondence to: John Greene, MD, Infectious Diseases and Infection

Prevention, Moffitt Cancer Center, 12902 Magnolia Dr, MailstopFOB-3, Tampa, FL 33612. E-mail: [email protected].

The authors have no funding or conflicts of interest to disclose.Copyright * 2013 by Lippincott Williams & WilkinsISSN: 1056-9103

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

consistent with aplasia. The patient was administered granulo-cyte colony-stimulating factor, which was continued untilthe absolute neutrophil count reached 3000 cells/KL. About12 days after the bone marrow biopsy while on voriconazole,meropenem, and daptomycin, the patient developed right-eyeinjection, itchiness, and clear discharge along with blurred vi-sion. The patient received a dose of methylprednisolone. Thenext day, ophthalmic evaluation revealed a worsening of thevitritis. A vitreous tap was done and came out dry. Aweek later,a vitrectomy yielded rare fungal elements on cytopathology,fungal elements on Gram stain, and more than 100 colonies ofFusarium species on chocolate and Sabouraud agar inoculatedwith the vitreous. Intravitreal injections of voriconazole andamphotericin B were given at the time of vitrectomy. Steroidswere discontinued. The patient developed renal failure and par-oxysmal atrial tachycardia as well as deep venous thrombosisof the right lower limb diagnosed 12 days after admission,which was managed with an inferior venous cava filter in viewof a low platelet count making him a poor candidate for antic-oagulation. The patient further developed a retinal detachmentof the right eye despite a decrease in the size of the fungalinfiltrate in the vitreous (Fig. 2). Retinal reattachment was at-tempted but failed, and the patient ultimately underwent right-eye enucleation.

Case 3Hewas a 46-year-old Hispanic man with acute lymphoblas-

tic leukemia (ALL) with central nervous system involvement,refractory to treatment, and complicated by brain lesions consis-tent with Toxoplasma versus fungal mold. He had a history ofculture-diagnosed Candida infection in the liver, Fusarium in-fection of the skin, and Fusarium and Aspergillus infection inhis sinuses for which he was treated with long-term voricona-zole. He developed a wrist lesion on which a biopsy was per-formed, which was found to be Fusarium and was treated withamphotericin B. The lesion resolved, and he developed periorbitalcellulitis and sinusitis that was found to be caused by Aspergillusand Fusarium. This was treated with amphotericin B and vori-conazole, leading to resolution. He then developed multiplebrain abscesses, thought to be mold or toxoplasmosis, and hewas continuously on voriconazole and co-trimoxazole, whilehis ALL progressed. He had right-eye involvement with a lesionthat looked like fungal retinitis. The patient was advised to seekan ophthalmologic evaluation, but did not follow up. Subse-quent ophthalmic outcome is unknown. In view of the clinicalpresentation and the clinical course, the patient probably hadmold endophthalmitis most likely due to Fusarium species.

DISCUSSIONEndogenous endophthalmitis accounts for only 2% to 8%

of cases of endophthalmitis and usually occurs in a relativelyimmunocompromised state.1 Cancer was found to be an under-lying condition in 7% of endogenous endophthalmitis in a caseseries by Leibovitch et al.2 The most common agents identifiedas causes of endogenous endophthalmitis have been Candidaspecies followed by Aspergillus species in various studies.3Y5

Endogenous fungal endophthalmitis is a known complicationof disseminated fungal infections. Feman,6 in a review of litera-ture, reported the frequency of endogenous fungal endophthal-mitis among patients with systemic fungal infections to varybetween 9% and 45%, whereas review of the author’s own casesindicated less than 2% of patients with disseminated fungalinfections had endophthalmitis. Most of their cases yieldedCandida species when cultured. Immunocompromise and intra-venous drug use are the 2 most common causes of endogenousendophthalmitis due to molds.7 Riddell,8 in a review of litera-ture of endogenous Aspergillus endophthalmitis from 1949 to2001, found underlying predisposing conditions to be intrave-nous drug use (27%), solid organ transplant (23%), chronic lungdisease (17%), corticosteroid treatment (43%), hematologic ma-lignancy (8%), and other malignancy (1%). Another study of23 cancer patients with fungal endophthalmitis confirmed thepropensity of cancer patients with mold endophthalmitis to havea hematologic malignancy. One hundred percent of the patientswith mold endophthalmitis (n = 15) had a hematologic malig-nancy; Fusarium species and Scedosporium apiospermum werethe most common offending agents.9 This, and other studies, al-so found that mold endophthalmitis is more frequently observedin patients after stem cell transplantation, and most of them hadactive malignancy at the time of the fungal endophthalmitis.9Y11

We observed similar findings in our 3 patients. All of themhad active hematologic malignancy at the time of diagnosis, andone had undergone a stem cell transplantation (case 1). The pre-senting symptom in our patients was conjunctival injection in2 cases. Diminution of vision was present with conjunctival in-jection and watering in 1 patient. All 3 patients in our reviewhad right-eye involvement, which is the most common eye tobe affected because of the more proximal and direct blood flowto the right carotid system.7 Diagnosis of Fusarium endophthal-mitis requires a high index of suspicion and can be difficult evenwith vitreous biopsy, and culture of the primary site should besought for identification. The primary site of disseminatedfusariosis resulting in endogenous endophthalmitis is generallythe skin, gastrointestinal tract, or the respiratory tract.12Y15 Theskin was the confirmed primary site in 2 of our cases (cases1 and 2), and the respiratory tract (sinuses) and/or skin wasthe probable focus in 1 case (case 3).

FIGURE 1. Hyaline septate fungal hyphae of Fusarium withrandom branching (case 1).

FIGURE 2. Right-eye endogenous Fusarium endophthalmitis withretinochoroidal involvement, retinal detachment, and vitrealbreakthrough with hemorrhage (case 2).

Infectious Diseases in Clinical Practice & Volume 21, Number 1, January 2013 Endogenous Fusarium Endophthalmitis

* 2013 Lippincott Williams & Wilkins www.infectdis.com 7


TABLE

1.CaseRe

portsof

Endo

geno

usFusariu

mEn

doph

thalmitis

Reference

No.

Cases

Visual

Outcom

eSurvival

Postdiagn

osis

Underlying

Con

dition

Systemic

Antifungals

Primary

Site

Ocular

Procedures

Culture

Positive

forVitrectom

y

Culture

Positivefor

PrimarySite

Cho

etal25

1V

VALL

VSkin

Vitrectomy

Fusarium

solani

F.solani

Lieberm

anetal26

1Enu

cleatio

nV

Steroids

Noantifun

gal

agents

VVitrectomy

F.solani

V

Anaissieetal27

1Patient

died

2wk

Chron

icmyelogeno

usleuk

emia

Amph

otericin

BHard palate

and

maxillarysinu

s

VV

Fusarium

oxyspo

rum

Anaissieetal27

1Patient

died

7d

Multip

lemyeloma

Amph

otericin

Bandrifampin

Fourth

leftfing

erV

VF.oxyspo

rum

Venditti

etal28

1Lossof

vision

VAML

Intravenou

sam

photericin

B,

5-fluorocytosine

Skin

VV

Blood

cultu

repo

sitiv

efor

F.solani

Com

haire-

Poutchinianetal29

1Partialvisual

recovery

(4/100

),developm

ent

ofcataract

VSteroids,

kidn

eyinfection

Treatment:

amph

otericin,

5-fluorocytosine;

prop

hylaxis:

itracon

azole

Kidney/skin/

urinarytract

VFusarium

V

Robertson

etal30

1Enu

cleatio

nV

AML

Amph

otericin

BV

VFusarium

VLou

ieetal31

14/20

036

dAtypical

refractory

AML

Amph

otericin,

flucon

azole

Unk

nown

Vitrectomy

with

intravitreal

amph

otericin

B

Positiv

e(F.solani)

Blood

cultu

repo

sitiv

efor

F.solani

Pateletal32

1Patient

died

VALL

Amph

otericin

B,

5-fluorocytosine

VIntravitreal

amph

otericin

BFusarium

V

Gabrieleand

Hutchins3

31

Fullrecovery

ofvision

VIntravenou

sdrug

use

Amph

otericin

BV

Intravitreal

amph

otericin

BFusarium

dimerium

V

Tiribellietal34

1No

VAML

liposom

alAmph

otericin

BV

VF.solani

V

Glasgow

etal35

1Patient

died

in2wk

2wk

AID

S/

cytomegalovirus

retin

itis

Amph

otericin

BIntravitreal

amph

otericin

BV

V

Rezaiet

al36

1Patient

died

4d

Myelody

splastic

synd

rome

converted

toAML

Amph

otericin

BIntravitreal

amph

otericin

BF.solani

V

Malavade et al Infectious Diseases in Clinical Practice & Volume 21, Number 1, January 2013

8 www.infectdis.com * 2013 Lippincott Williams & Wilkins


TABLE

2.Re

view

ofLiterature

forEn

doge

nous

Fusariu

mEn

doph

thalmitis

Sr.

no

Author

Journal

Year

No.

Cases

Visual

Outcom

eSurvival

Postdiagn

osis

Underlying

Con

dition

Systemic

Antifungals

Primary

Site

Vitrectom

yWith

Intravitreal

Antibiotics

Culture

Positivefor

Vitrectom

y

Culture

Positive

forPrimary

Site

1Cho

etal

JPediatr

1973

1V

VALL

VSkin

Vitrectomy

F.solani

Yes,skin

andeye

2Lieberm

anetal26

AmJ

Ophthalmol

1979

1Enu

cleatio

nV

Steroids

No an

tifun

gal

agents

VVitrectomy

F.solani

V

3Anaissieetal27

Can

cer

1986

1Patient

died

2wk

Chron

icmyelogeno

usleuk

emia

Amph

otericin

BHardpalate

and

maxillary

sinu

s

VV

Yes,F.

oxyspo

rum

4Anaissieetal27

Can

cer

1986

1Patient

died

7d

Multip

lemyeloma

Amph

otericin

Bandrifampin

Fourth

left

fing

erV

VYes,F.

oxyspo

rum

5Vendittietal28

Rev

Infect

Dis

1988

1Lossof

vision

VAML

Intravenou

sam

photericin

B,

5-fluorocytosine

Skin

VV

Blood

culture

positivefor

F.solani

6Com

haire-

Poutchinian

etal29

BullSo

cBelge

Oph

thalmol

1990

1Partial

visual

recovery

(4/100

),developm

ent

ofcataract

VSteroids,

kidn

eyinfection

Treatment:

amph

otericin,

5fluo

rocytosine;

prop

hylaxis:

itracon

azole

Kidney/

skin/urinary

tract

VFusarium

V

7Rob

ertson

etal30

Bon

eMarrow

Tran

splant

1991

1Enu

cleatio

nV

AML

Amph

otericin

BV

VFusarium

V

8Lou

ieetal31

ClinInfectDis

1994

14/20

036

dAtypical

refractory

AML

Amph

otericin,

flucon

azole

Unk

nown

Vitrectomy

with

intravitreal

amph

otericin

B

Positiv

e(F.solani)

Blood

culture

positivefor

F.solani

9Pateletal32

Am

JOph

thalmol

1994

1Patient

died

VALL

Amph

otericin

B,

5-fluo

rocytosine

VIntravitreal

amph

otericin

BFusarium

Eye

10Gabriele

andHutchins3

3Am

JOph

thalmol

1996

1Full recovery

ofvision

VIntravenou

sdrug

use

Amph

otericin

BV

Intravitreal

amph

otericin

BF.dimerium

Eye

11Tiribellietal34

Eur

JHaematol

2002

1No

VAML

Liposom

alam

photericin

BV

VF.solani

Skinand

lung

s12

Glasgow

etal35

Arch Oph

thalmol

1996

1Patient

died

in2wk

2wk

AID

S/

cytomegalovirus

retin

itis

Amph

otericin

BIntravitreal

amph

otericin

BV

Eye

13Rezai

etal36

Arch Oph

thalmol

2005

1Patient

died

4d

Myelody

splastic

synd

rome

converted

toAML

Amph

otericin

BIntravitreal

amph

otericin

BF.solani

Eye




The optimal treatment of invasive fusarial infections hasyet to be determined.16 Amphotericin B in its lipid formulationis commonly combined with an azole agent for the treatment ofinvasive fusariosis.17,18 Voriconazole has been approved fortreatment of Fusarium infections since 2002. Stanzani et al,19

in their review of literature, reported 69% of invasive fusariosisto have been successfully treated with voriconazole. Lortholaryet al16 did not find any statistically significant difference be-tween combination therapy and therapy with voriconazole alonein their international retrospective analysis of 73 cases of invasivefusariosis treated with voriconazole. Posaconazole is another an-tifungal agent with a wide spectrum for difficult-to-treat infec-tions that include zygomycosis, Scedosporium species, andFusarium species and is available as an oral suspension. Howev-er, posaconazole can have variable absorption after oral admin-istration.20 It has been reported that posaconazole and theechinocandins do not achieve adequate therapeutic levels inthe vitreous.21 There are reports of posaconazole being usedto successfully treat ocular fusariosis. In one, the patient wasimmunocompetent with Fusarium keratitis and secondary en-dophthalmitis that was treated with oral and topical posacona-zole. That patient had a descemetocele that decompressed andcould have been responsible for the high intraocular concentra-tions of posaconazole noted.22 In the other study, posaconazolewas used as a salvage medication to treat patients unable to tol-erate voriconazole or whose ocular fusariosis was resistant tovoriconazole.23 Posaconazole can be considered in patients in-tolerant to amphotericin B or voriconazole for the treatment ofocular fusariosis. Identification of the species of Fusarium caus-ing the infection has been recommended because of their vari-able susceptibilities to antifungal agents.24 All of our patientsreceived systemic antifungal therapyVamphotericin B and itra-conazole (case 1) and liposomal amphotericin B and vorico-nazole (cases 2 and 3). Local therapy included intravitrealinjection of amphotericin B (case 1) and voriconazole (case 2).Complications of treatment included renal insufficiency with li-posomal amphotericin B (case 2) necessitating change of thera-py to voriconazole. The ophthalmic outcome was enucleationfollowing multiple injections and surgeries and unsuccessful at-tempt at retinal detachment repair (case 2). One patient diedwhile on treatment (case 1), and the other was lost to follow-up(case 3). Thevisual outcome of endogenousFusarium endophthal-mitis is uniformly poor in patients with hematologic malignan-cies, as is evident from previously reported cases (Table 1).Survival outcomes in patients with disseminated Fusarium arepoor, with 100% mortality in neutropenic patients in a retro-spective study by Nucci and Annaissie.24 A detailed metastaticevaluation for fungal infection should be done in these patientsincluding ocular posterior segment examination to detect en-dogenous endophthalmitis before symptom onset and signifi-cant progression.

Table 2 summarizes the reported cases of endogenousFusarium endophthalmitis in literature before this report.

SUMMARYThis report presents 3 cases of endogenous Fusarium en-

dophthalmitis in patients with hematologic malignancies andreviews the literature of this rare condition. It summarizes an in-creasingly frequent fungal infection with ocular involvement inimmunocompromised patients with malignancies of the hemato-poietic system and stresses the importance of detailed metastaticfungal evaluation including ocular posterior segment examinationalong with laboratory confirmation for early diagnosis and man-agement of this condition.

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