Aspergillus endophthalmitis in a large B-cell lymphoma patient

Khatereh Mousavi-Fatemi; Nazanin Ebrahimi Adib; Sahar Khosravi; Mohsen Dehdashti; Mohammad Biglari

doi:10.4103/joah.joah_39_21

CASE REPORT

Year : 2021 | Volume : 12 | Issue : 4 | Page : 224-226

Aspergillus endophthalmitis in a large B-cell lymphoma patient

Khatereh Mousavi-Fatemi¹, Nazanin Ebrahimi Adib², Sahar Khosravi¹, Mohsen Dehdashti¹, Mohammad Biglari³
¹ Hematologist and Medical Oncologist, Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
² Department of Ophtalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
³ Fellowship of Hematology and Medical Oncology, Hematology, Oncology and Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran

Date of Submission	20-May-2021
Date of Decision	10-Jun-2021
Date of Acceptance	17-Jun-2021
Date of Web Publication	18-Jan-2022

Correspondence Address:
Dr. Mohammad Biglari
Shariati Hospital, N. Kargar St., 14114-13137, Tehran
Iran

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/joah.joah_39_21

Abstract

To highlight the graveness of invasive Aspergillus infections that could end in serious complications in immunocompromised patients, we are going to report a rare case of bilateral Aspergillus endophthalmitis in a lymphoma patient. We present a case in an academic referring hospital. The patient was an immunocompromised patient with diffuse large B-cell lymphoma complicated with vision loss due to Aspergillus infection diagnosed with B-mode ultrasound and culture and followed by treatment with vitrectomy and intravitreous amphotericin. The patient was followed for 9 months, culminating in visual acuity of 4/100 and 1/100 in her left and right eye, respectively. Despite appropriate diagnosis and treatment, invasive Aspergillus infection may still have a poor prognosis.

Keywords: Aspergillus, case report, endophthalmitis, lymphoma, treatment

How to cite this article:
Mousavi-Fatemi K, Adib NE, Khosravi S, Dehdashti M, Biglari M. Aspergillus endophthalmitis in a large B-cell lymphoma patient. J Appl Hematol 2021;12:224-6

How to cite this URL:
Mousavi-Fatemi K, Adib NE, Khosravi S, Dehdashti M, Biglari M. Aspergillus endophthalmitis in a large B-cell lymphoma patient. J Appl Hematol [serial online] 2021 [cited 2023 Oct 3];12:224-6. Available from: https://www.jahjournal.org/text.asp?2021/12/4/224/335943

Introduction

Aspergillus infection is usually observed in immunocompromised patients and there are few reports about Aspergillosis in healthy individuals.^[1],[2] Typical findings in a disseminated form of aggressive Aspergillosis usually involve the brain, heart, and skin tissues. However, endophthalmitis is a rare complication with the unfavorable outcome with ocular lesions mostly caused by disseminating organisms from adjacent organs. Here, we report a patient with diffuse large B-cell lymphoma who developed endogenous endophthalmitis caused by Aspergillus. Authors declare that written informed consent was given by the patient for publishing the data and also the figures presented here.

Case Report

A 52-year-old Caucasian woman was referred to our hospital with constitutional symptoms (low-grade fever, and weight loss), anemia, huge splenomegaly, and generalized lymphadenopathy. Diffuse large B-cell lymphoma (Ann-Arbor Stage IV) was diagnosed after initial workup and bone marrow aspiration/biopsy. Seven days after receiving CVP (cyclophosphamide 500 mg on Day one; vincristine 2 mg on Day one; prednisolone 50 mg, Days one to five) regimen, an acute decrease in visual acuity occurred in her both eyes. She has no relevant family history or genetic susceptibility.

Her laboratory results included a leukocyte count of 400/μL, hemoglobin 7.8 g/L, platelet count of 23,000/μL, and normal renal and hepatic function. Ophthalmology consult was requested. Her visual acuity was as light perception in the right eye and hand motion in the left eye. Slit-lamp examination revealed two to three plus cells and flare in addition to 360° posterior synechia obscuring retinal examination in the anterior segment of both eyes [Figure 1]. The patient was ill with red and painful eyes so could not cooperate for intraocular pressure measurement. Retinal examination was done by indirect ophthalmoscopy revealing a hazy view with no retinal vessels identifiable.

Figure 1: Slit photos of the right (a) and left (b) eyes at initial presentation. Ultrasound B-scan showed vitreous involvement (c) and there were 2–3 + cell and flare in anterior chamber and a posterior synechia was evident. Retina was not visible

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The patient underwent emergent pars plana vitrectomy using a three-port setup. First, a 0.5 ml undiluted vitreous specimen was obtained with aspiration. Then infusion started and core vitrectomy performed, during which heavy cellular infiltration was removed from the vitreous cavity and anterior chamber. Both undiluted and diluted samples were sent for smear, culture, polymerase chain reaction, and flow-cytometry evaluation. Retina was attached and a localized vasculitis was observed around the lesion. Silicone oil was injected after fluid air exchange. Empirical antibiotic injection was also performed using vancomycin 1 mg/0.1 ml and ceftazidime 2.25 mg/0.1 ml.

After obtaining a positive culture for Aspergillus fumigatus, intravitreal amphotericin B injection (10 μg/0.1 ml) was administered. Flow cytometry failed to show any clonality and no lymphoma cell markers were detected. The patient was treated with oral voriconazole 400 mg twice daily for 1 day and then 200 mg twice daily for 6 weeks. Blood cultures turned negative and spiral paranasal and chest computed tomography were unremarkable. After 9 months, in her last follow-up, visual acuity in her left eye (with better vision) was 4/100 and there was temporal macular dragging due to subretinal fibrosis in the macular area [Figure 2]. The right eye showed a visual acuity of 1/100.

Figure 2: Fundus photos of the right (a) and left (b and c) eyes of the patient. There was large hemorrhage and vascular sheathing is evident in the left eye (arrow). 9-months postoperation photos (d and e)

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Discussion

Fungal endophthalmitis has an insidious onset; however, Aspergillus species usually have a rapid progression.^[3] Although Aspergillus endophthalmitis is usually caused by an exogenous source, it can be the pathogen in endogenous cases as well. Candida (yeast) is the most common fungal pathogen in endogenous endophthalmitis;^[4] however, some reports from India state Aspergillus (mold) as the most common pathogen in endogenous endophthalmitis.^[5]

The condition is almost limited to immunocompromised patients or intravenous drug users. Therefore, it is reasonable to think of the recent chemotherapy as a predisposing factor in our presented case. Aspergillus as a culprit pathogen for endophthalmitis has been reported rarely. One such case was reported by Prakash et al. describing endophthalmitis with Aspergillus fumigatus in a middle-aged man suffering from angioimmunoblastic T-cell lymphoma.^[6] This condition has the propensity to involve the posterior pole as well, so the long-term visual prognosis is poor.^[2] Our patient had the same involvement in the posterior retina but bilateral presentation without obvious extraocular source was unusual.

In the absence of treatment, subsequent fungal proliferation causes vitreous inflammation and spreading to the anterior chamber occurs. At the initial presentation, there was no conjunctival inflammation in our patient, which implies the early stage of the disease. Early diagnosis and urgent vitrectomy with intravitreal injection of amphotericin B or voriconazole are the mainstay of treatment, since intravenous antifungals have poor penetration into the orbit.^[2],[7] However, the general prognosis remains poor due to macular involvement and scar. Despite prompt diagnosis and vitrectomy for the patient, she ended up with poor visual acuity although improved partially in her left eye. She managed to have her chemotherapy course completely and underlying lymphoma is now in remission.

In conclusion, despite appropriate diagnosis and treatment, invasive Aspergillus infection may still have a poor prognosis.

Consent

The authors clarify that all appropriate written consent forms are taken from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Patient perspective

“I was an active and sociable person before my first symptoms appeared and I was diagnosed with B Lymphoma at Shariati hospital in Tehran. Soon after I was told that I must start chemotherapy as soon as possible. It was so hard to believe for me and to accept the role of an ill woman for at least a year from that time according to my physician's advice. I did not hesitate to get involved in the long and cumbersome course of chemotherapy despite its potential threats and dangers. Happily, my symptoms improved rapidly and I experienced a bounce up in my overall well-being. All of a sudden, one of those complications rose up right to my face. I experienced a sudden loss of vision in my both eyes. I was so scared and it was more than I could bear. My physician promptly arranged for an eye consult and I was transferred to a well-equipped ophthalmology hospital. My fungal infection was treated as fast as it could be in hope of regaining my sight. Well, the infection was cured, yet my vision did not improve to its maximum; but I am now able to somehow manage my affairs accordingly.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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