- Email: [email protected]
Endogenous Endophthalmitis Caused by Bipolaris hawaiiensis in a Patient With Acquired Immunodeficiency Syndrome
644
AMERICAN JOURNAL OF OPHTHALMOLOGY
Endogenous Endophthalmitis Caused by Bipo/aris hawaiiensis in a Patient With Acquired Immunodeficiency Syndrome
30 Cl
::E:
E E
.. ..
a)
::l III III CIl
0.
e
25
Peter R. Pavan, M.D., and Curtis E. Margo, M.D.
20
Departments of Ophthalmology (P.R.P., C.E.M.) and Pathology (C.E.M.), University of South Florida, College of Medicine.
15
CIl
Q, I
0
c 10 0
~
5+----r-----r---"T--........,.----( 5
10
15
20
25
30
Goldmann Applanation Pressure, mm Hg
Fig. 2 (Kupin and associates). Linear regression showing the patient's Tono-Pen intraocular pressures measured in the clinic compared to the concurrent Goldmann applanation pressures (y = 3.65 + 0.79x, r
=
November, 1993
.83; P
=
.0001).
onstrated by our patient. Home tonometry has disclosed marked early-morning pressure spikes in many patients with chronic open-angle glaucoma and also in some patients with presumed low-tension glaucoma, who had normal intraocular pressures measured during office hours.>' Although careful patient selection may be necessary, as the applications for the home tonometer increase, the instrument's widespread use may become an important adjunct in the treatment of glaucoma.
References 1. Jensen, A. D., and Maumenee, A. E.: Home tonometry. Am. J. Ophthalmol. 76:929, 1965. 2. Alpar, J. J.: The use of home tonometry in the diagnosis and treatment of glaucoma. Glaucoma
5: 130, 1983.
3. Wilensky, J. T., Gieser, D. K., Mori, M. T., Langenberg, P. W., and Zeimer, R. c.: Self-tonometry to manage patients with glaucoma and apparently controlled intraocular pressure. Arch. Ophthalmol. 105:1072,1987.
4. Stewart, W. c., Cascairo, M. A., and Banta, R.: The use of a new portable noncontact tonometer in home tonometry. Ann. Ophthalmol. 23:377, 1991. 5. Frenkel, R. E., Hong, Y. J., and Shin, D. H.: Comparison of the Tone-pen to the Goldmann applanation tonometer. Arch. Ophthalmol. 106:750,1988.
Inquiries to Peter R. Patian, M.D., University of South Florida, College of Medicine, 12901 Bruce Downs Blvd., MOC Box 21, Tampa, FL 33612. Bipolaris species are ubiquitous dematiaceous fungi (previously Drechslera), which cause a variety of clinical infections including sinusitis, keratitis, and meningoencephalitis.!" Infected patients are often immunocompetent.t" although some have underlying diseases such as cancer or lymphoma.':' We treated a patient with acquired immunodeficiency syndrome (AIDS) who developed bilateral endogenous endophthalmitis caused by B. hawaiiensis. A 26-year-old man who had AIDS for six years had bilateral decreased vision for three weeks. He had chronic diarrhea for the previous two months and was taking oral fluconazole, 200 mg/day, for oral candidiasis. He had discontinued zidovudine because of its side effects. Best-corrected visual acuity was R.E.: 20/300 and L.E.: 20/50. Findings on ocular examination included a mild cellular reaction in the anterior chamber and vitreous and multiple retinal infiltrates in the posterior pole of each eye (Figure). A cellular reaction was present in the cortical vitreous above the retinal infiltrates. The disks were mildly swollen. Results of general physical examination and laboratory studies, including cultures of urine, blood, and cerebrospinal fluid, yielded no source of infection for the ocular lesions. A full-thickness biopsy of the retina and vitreous from the right eye was performed. No intraocular antimicrobial therapy was given. The biopsy specimen disclosed scattered neutrophils and focal retinal necrosis; modified Gram and periodic acid-Schiff stains disclosed no organisms. Postoperatively the inflammation worsened in both eyes. A regimen of oral clindamycin was begun empirically, but the inflammation progressed. Cultures from the right vitreous grew a fungus resembling yeast 15 days postoperatively. The patient was treated with intravitreal amphotericin B, 5 ,...g in each eye, and intravenous amphotericin B for six weeks. Oral flucon-
Vol. 116, No.5
Letters to The Journal
645
Figure (Pavan and Margo). Left, Fundus of the right eye. Right, Fundus of the left eye. Both show multiple, white retinal lesions with overlying vitreitis and swelling of the optic disks.
azole was continued for several months. The clinical course was complicated by a vitreal hemorrhage in each eye several weeks into therapy; the hemorrhages slowly resorbed. Nine months later, visual acuity was R.E.: 20/ 30 and L.E.: 20/40. The organism was eventually identified as B. haiouiiensie and was shown to be sensitive to both amphotericin B (minimum inhibitory concentration [MIC] was 0.1 j.Lg/mL) and fluconazole (MIC was 0.4 j.Lg/mL). Optimal antimicrobial therapy for infection with Bipolaris organisms is not known.' Amphotericin B has been effective in some but not all patients with orbital and sinus infection.' Most species of Bipolaris are resistant to 5flucytosine in vitro.' Our patient developed endogenous Bipolaris endophthalmitis while taking oral fluconazole. This observation, however, must be interpreted with caution because compliance with self-medication had been a problem.
3. Maskin, S. L., Fetchick, R. J., Leone, C. R., Jr., Sharkey, P. K., and Rinaldi, M. G.: Bipolaris hawaiiensis-caused phaeohyphomycotic orbitopathy. A devastating fungal sinusitis in an apparently immunocompetent host. Ophthalmology 96:175,1989. 4. Jacobson, M., Caletta. S. L., Atlas, S. W., Curtis, M. T., and Wulc, A. W.: Bipolaris-induced orbital cellulitis. J. Clin. Neuro. Ophthalmol. 12:250, 1992. 5. Fuste, F. J., Ajello, L., Threlkeld, R., and Henry, J. E., [r.: Drechslera hawaiiensis. Causative agent of a fatal fungal meningo-encephalitis. Sabouraudia
References
Section of Ophthalmology, Department of Surgery, University of Tennessee Medical Center at Knoxville; and Ophthalmology Service, Department of Surgery, East Tennessee Baptist Hospital.
1. Adam, R. D., Paquin, M. L., Petersen, E. A., Saubolle, M. A., Rinaldi, M. G., Corcoran, J. G., Galgiant J. N., and Sobonya, R. E.: Phaeohyphomycosis caused by fungal genera Bipolaris and Exserohilum. A report of 9 cases and review of the literature. Medicine 65:203, 1986. 2. Jay, W. M., Bradsher, R. W., LeMay, B., Snyderman, N., and Angtuaco, E. J.: Ocular involvement in mycotic sinusitis caused by Bipolaris. Am. J. Ophthalmol. 105:366, 1988.
11:59,1973.
Prevention of Enucleation of Two Phthisic Eyes by Removal of Extruding Silicone Scleral Buckles Herbert J. Glatt, M.D., and James H. Miller, Jr., M.D.
Inquiries to Herbert J. Glatt, M.D., University Eye Surgeons, 1928 Alcoa Hwy., Knoxville, TN 37920.
Partial scleral buckle extrusion can result in pain because of either infection or an inflammatory reaction to dystrophic calcification on the buckle. 1 Pain caused by partial scleral buckle extrusion can be relieved by removal of the
AMERICAN JOURNAL OF OPHTHALMOLOGY
Endogenous Endophthalmitis Caused by Bipo/aris hawaiiensis in a Patient With Acquired Immunodeficiency Syndrome
30 Cl
::E:
E E
.. ..
a)
::l III III CIl
0.
e
25
Peter R. Pavan, M.D., and Curtis E. Margo, M.D.
20
Departments of Ophthalmology (P.R.P., C.E.M.) and Pathology (C.E.M.), University of South Florida, College of Medicine.
15
CIl
Q, I
0
c 10 0
~
5+----r-----r---"T--........,.----( 5
10
15
20
25
30
Goldmann Applanation Pressure, mm Hg
Fig. 2 (Kupin and associates). Linear regression showing the patient's Tono-Pen intraocular pressures measured in the clinic compared to the concurrent Goldmann applanation pressures (y = 3.65 + 0.79x, r
=
November, 1993
.83; P
=
.0001).
onstrated by our patient. Home tonometry has disclosed marked early-morning pressure spikes in many patients with chronic open-angle glaucoma and also in some patients with presumed low-tension glaucoma, who had normal intraocular pressures measured during office hours.>' Although careful patient selection may be necessary, as the applications for the home tonometer increase, the instrument's widespread use may become an important adjunct in the treatment of glaucoma.
References 1. Jensen, A. D., and Maumenee, A. E.: Home tonometry. Am. J. Ophthalmol. 76:929, 1965. 2. Alpar, J. J.: The use of home tonometry in the diagnosis and treatment of glaucoma. Glaucoma
5: 130, 1983.
3. Wilensky, J. T., Gieser, D. K., Mori, M. T., Langenberg, P. W., and Zeimer, R. c.: Self-tonometry to manage patients with glaucoma and apparently controlled intraocular pressure. Arch. Ophthalmol. 105:1072,1987.
4. Stewart, W. c., Cascairo, M. A., and Banta, R.: The use of a new portable noncontact tonometer in home tonometry. Ann. Ophthalmol. 23:377, 1991. 5. Frenkel, R. E., Hong, Y. J., and Shin, D. H.: Comparison of the Tone-pen to the Goldmann applanation tonometer. Arch. Ophthalmol. 106:750,1988.
Inquiries to Peter R. Patian, M.D., University of South Florida, College of Medicine, 12901 Bruce Downs Blvd., MOC Box 21, Tampa, FL 33612. Bipolaris species are ubiquitous dematiaceous fungi (previously Drechslera), which cause a variety of clinical infections including sinusitis, keratitis, and meningoencephalitis.!" Infected patients are often immunocompetent.t" although some have underlying diseases such as cancer or lymphoma.':' We treated a patient with acquired immunodeficiency syndrome (AIDS) who developed bilateral endogenous endophthalmitis caused by B. hawaiiensis. A 26-year-old man who had AIDS for six years had bilateral decreased vision for three weeks. He had chronic diarrhea for the previous two months and was taking oral fluconazole, 200 mg/day, for oral candidiasis. He had discontinued zidovudine because of its side effects. Best-corrected visual acuity was R.E.: 20/300 and L.E.: 20/50. Findings on ocular examination included a mild cellular reaction in the anterior chamber and vitreous and multiple retinal infiltrates in the posterior pole of each eye (Figure). A cellular reaction was present in the cortical vitreous above the retinal infiltrates. The disks were mildly swollen. Results of general physical examination and laboratory studies, including cultures of urine, blood, and cerebrospinal fluid, yielded no source of infection for the ocular lesions. A full-thickness biopsy of the retina and vitreous from the right eye was performed. No intraocular antimicrobial therapy was given. The biopsy specimen disclosed scattered neutrophils and focal retinal necrosis; modified Gram and periodic acid-Schiff stains disclosed no organisms. Postoperatively the inflammation worsened in both eyes. A regimen of oral clindamycin was begun empirically, but the inflammation progressed. Cultures from the right vitreous grew a fungus resembling yeast 15 days postoperatively. The patient was treated with intravitreal amphotericin B, 5 ,...g in each eye, and intravenous amphotericin B for six weeks. Oral flucon-
Vol. 116, No.5
Letters to The Journal
645
Figure (Pavan and Margo). Left, Fundus of the right eye. Right, Fundus of the left eye. Both show multiple, white retinal lesions with overlying vitreitis and swelling of the optic disks.
azole was continued for several months. The clinical course was complicated by a vitreal hemorrhage in each eye several weeks into therapy; the hemorrhages slowly resorbed. Nine months later, visual acuity was R.E.: 20/ 30 and L.E.: 20/40. The organism was eventually identified as B. haiouiiensie and was shown to be sensitive to both amphotericin B (minimum inhibitory concentration [MIC] was 0.1 j.Lg/mL) and fluconazole (MIC was 0.4 j.Lg/mL). Optimal antimicrobial therapy for infection with Bipolaris organisms is not known.' Amphotericin B has been effective in some but not all patients with orbital and sinus infection.' Most species of Bipolaris are resistant to 5flucytosine in vitro.' Our patient developed endogenous Bipolaris endophthalmitis while taking oral fluconazole. This observation, however, must be interpreted with caution because compliance with self-medication had been a problem.
3. Maskin, S. L., Fetchick, R. J., Leone, C. R., Jr., Sharkey, P. K., and Rinaldi, M. G.: Bipolaris hawaiiensis-caused phaeohyphomycotic orbitopathy. A devastating fungal sinusitis in an apparently immunocompetent host. Ophthalmology 96:175,1989. 4. Jacobson, M., Caletta. S. L., Atlas, S. W., Curtis, M. T., and Wulc, A. W.: Bipolaris-induced orbital cellulitis. J. Clin. Neuro. Ophthalmol. 12:250, 1992. 5. Fuste, F. J., Ajello, L., Threlkeld, R., and Henry, J. E., [r.: Drechslera hawaiiensis. Causative agent of a fatal fungal meningo-encephalitis. Sabouraudia
References
Section of Ophthalmology, Department of Surgery, University of Tennessee Medical Center at Knoxville; and Ophthalmology Service, Department of Surgery, East Tennessee Baptist Hospital.
1. Adam, R. D., Paquin, M. L., Petersen, E. A., Saubolle, M. A., Rinaldi, M. G., Corcoran, J. G., Galgiant J. N., and Sobonya, R. E.: Phaeohyphomycosis caused by fungal genera Bipolaris and Exserohilum. A report of 9 cases and review of the literature. Medicine 65:203, 1986. 2. Jay, W. M., Bradsher, R. W., LeMay, B., Snyderman, N., and Angtuaco, E. J.: Ocular involvement in mycotic sinusitis caused by Bipolaris. Am. J. Ophthalmol. 105:366, 1988.
11:59,1973.
Prevention of Enucleation of Two Phthisic Eyes by Removal of Extruding Silicone Scleral Buckles Herbert J. Glatt, M.D., and James H. Miller, Jr., M.D.
Inquiries to Herbert J. Glatt, M.D., University Eye Surgeons, 1928 Alcoa Hwy., Knoxville, TN 37920.
Partial scleral buckle extrusion can result in pain because of either infection or an inflammatory reaction to dystrophic calcification on the buckle. 1 Pain caused by partial scleral buckle extrusion can be relieved by removal of the