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Pneumocystis carinii of the Orbit
Letters to The Journal
Vol. 113, No. 5
Concomitant endophthalmitis, vaginitis, and onychomycosis caused by Candida organisms in our patient might suggest some defect in cellmediated immunity that would facilitate dis seminated infection with Candida organisms. However, normal results of skin and lympho cyte function testing against Candida antigen, normal results of T-lymphocyte immunodefi ciency testing, and repeated negative serologic testing for HIV mitigate against immunosuppression. Endogenous endophthalmitis caused by Can dida organisms may develop in a healthy, immunocompetent patient who lacks the typical risk factors for this opportunistic infection, par ticularly if localized, extraocular infection with Candida organisms coexists.
References 1. Holland, G. N.: Endogenous fungal infections of the retina and choroid. In Ryan, S. J. (ed.): Retina, vol. 2. St. Louis, C. V. Mosby, 1989, p. 625. 2. McLean, J. M.: Oculomycosis. Am. J. Ophthalmol. 56:537, 1963. 3. Edwards, J. E., Foos, R. Y., Montgomerie, J. Z., and Guze, L. B.: Ocular manifestations of Candida septicemia. Review of seventy-six cases of hematogenous Candida endophthalmitis. Medicine 53:47, 1974. 4. Schmid, S., Martenet, A. C., and Oelz, O.: Can dida endophthalmitis. Clinical presentation, treat ment and outcome in 23 patients. Infection 19:21, 1991. 5. Daily, M. J., Dickey, J. B., and Packo, K. H.: Endogenous Candida endophthalmitis after intrave nous anesthesia with propofol. Arch. Ophthalmol. 109:1081, 1991.
Pneumocystis carinii of the Orbit Dorothy N. Friedberg, M.D., Floyd A. Warren, M.D., M o o n H. Lee, M.D., Christina Vallejo, M.D., and R. Christine M e l t o n , M.D. Department of Ophthalmology, New York University Medical Center (D.N.F., F.A.W.); and Departments of Pathology (M.H.L., C.V.) and Ophthalmology (F.A.W., R.C.M.), St. Vincent's Hospital.
595
Inquiries to Dorothy N. Friedberg, M.D., Department of Ophthalmology, New York University Medical Center, 550 First Ave., New York, NY 10016. The increased use of aerosolized pentamidine prophylaxis is believed to be instrumental in the rise of disseminated extrapulmonary Pneumocystis carinii infection. 1,2 Pneumocystis choroidopathy is a recently described example of ocular opportunistic infection in the ac quired immunodeficiency syndrome. 3 4 We en countered another ophthalmic manifestation of pneumocystis infection. The patient was a 32-year-old man in whom AIDS was diagnosed in April 1988 after an episode of P. carinii pneumonia. He was initial ly treated with trimethoprim and sulfamethoxazole. In September 1988 aerosolized pentamidine therapy was started. The patient's ophthalmic history was unremarkable until September 1989 when he was examined be cause of blurred vision and pain on movement in the right eye. Examination of the anterior segment including pupillary reaction was re ported to be normal. Ophthalmoscopy dis closed retinal edema, and a diagnosis of central serous retinopathy was considered. The patient returned two months later with increased blurred vision and pain on eye move ment in the right eye. Visual acuity in the right eye was 20/25, and there was mild edema of the right optic nerve inferiorly. Magnetic reso nance imaging of the head and orbit was nor mal. Over the next three weeks the patient's visual acuity in the right eye deteriorated to 20/200; color vision diminished; optic nerve edema increased; and an afferent pupillary de fect developed. Results of examination of the left eye continued to be normal. The patient was first seen for neuro-ophthalmic consultation in December 1989. Visual acu ity was R.E.: counting fingers at 6 feet, and L.E.: 20/15. All color plates were missed with the right eye, and the visual field was markedly constricted. An afferent pupillary defect was present. There was no proptosis or tenderness of the globe on retropulsion; motility was nor mal. There was mild swelling of the optic nerve and a diffuse loss of the nerve fiber layer. The left eye was normal. Magnetic resonance imag ing was normal, and a spinal tap with cytology was recommended. The patient refused and was lost to follow-up until April 1990. At that time visual acuity in the right eye was no light perception. There was 4 mm of proptosis and a
596
May, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
d e n c e of d i s s e m i n a t e d p n e u m o c y s t i s infection. The p a t i e n t d i e d in June 1 9 9 1 . N o a u t o p s y was obtained.
References
Fig. 1 (Friedberg and associates). Computed tomographic scan demonstrates diffuse right orbital mass.
m a s s on c o m p u t e d t o m o g r a p h i c scan; n e e d l e aspiration was nondiagnostic. The p a t i e n t refused further e x a m i n a t i o n u n t i l O c t o b e r 1990 w h e n h e was s e e n b e c a u s e of 9 m m of p r o p t o s i s a n d a n i n t r a c o n a l m a s s on c o m p u t e d t o m o g r a p h i c scan (Fig. 1). N e e d l e b i o p s y was a g a i n n o n d i a g n o s t i c , a n d a n o p e n biopsy was p e r f o r m e d . This s h o w e d g r a n u l o m a t o u s i n f l a m m a t i o n m i x e d w i t h foamy m a t e r i a l c o n t a i n i n g P. carinii o r g a n i s m s , d e m o n s t r a t e d w i t h silver m e t h e n a m i n e a n d G i e m s a s t a i n s (Fig. 2). The p a t i e n t w a s t r e a t e d w i t h t r i m e t h o p r i m a n d s u l f a m e t h o x a z o l e . The p r o p t o s i s r e s p o n d e d d r a m a t i c a l l y . T h e r e was n o o t h e r evi-
Fig. 2 (Friedberg and associates). Histologic section of the lesion shows granulomatous inflammation mixed with foamy amorphous material (hematoxylin and eosin, x 100). Upper inset, Cysts of P. carinii with wall thickening (Gomori's methenamine silver, x 1,000). Lower inset, Cyst of P. carinii with intracystic bodies (Giemsa, x 1,000).
1. Armstrong, D.: Aerosol pentamidine. Ann. In tern. Med. 109:852, 1988. 2. Raviglione, M. C , Mariuz, P., Sugar, J., and Mullen, M.: Extrapulmonary pneumocystis infection. Ann. Intern. Med. 111:339, 1989. 3. Rao, N. A., Zimmerman, P. L., Boyer, D., Bis was, J., Causey, D., Beniz, J., and Nichols, P. W.: A clinical, histopathologic, and electron microscopic study of Pneumocystis carinii choroiditis. Am. J. Ophthalmol. 107:218, 1989. 4. Shami, M. J., Freeman, W., Friedberg, D., Siderides, E., Listhaus, A., and Ai, E.: A multicenter study of Pneumocystis choroidopathy. Am. J. Ophthalmol. 112:15, 1991.
Propionibacterium acnes Keratitis Gerald W. Zaidman, M.D. Department of Ophthalmology, Westchester County Medical Center, New York Medical College. Pre sented at the Ocular Microbiology and Immunology Group Meeting, Anaheim, California, Oct. 12, 1991. Inquiries to Gerald W. Zaidman, M.D., Department of Ophthalmology, Westchester County Medical Center, Valhalla, NY 10595. Propionibacterium acnes is a u b i q u i t o u s or g a n i s m of low v i r u l e n c e c o m m o n l y f o u n d in s e b a c e o u s g l a n d s . 1 It is an o p p o r t u n i s t i c p a t h o gen that h a s b e e n associated w i t h infections of p r o s t h e t i c devices such as artificial h i p s , h e a r t valves, a n d i n t r a o c u l a r lenses. 2 In the eye, P. acnes h a s c a u s e d conjunctivitis, orbital a n d p r e s e p t a l cellulitis, a n d d e l a y e d e n d o p h t h a l m i tis. 1 I t r e a t e d a p a t i e n t w h o h a d P. acnes kerati tis. A 3 3 - y e a r - o l d w o m a n was referred in N o v e m b e r 1990. The p a t i e n t h a d a t w o - m o n t h history of i n t e r m i t t e n t p h o t o p h o b i a a n d for eign b o d y s e n s a t i o n in her r i g h t eye. She d e n i e d any allergies, t r a u m a , or c o n t a c t - l e n s w e a r . The p a t i e n t h a d b e e n t r e a t e d topically w i t h v a r i o u s a n t i b i o t i c s , c o r t i c o s t e r o i d s , a n d artificial tears. E x a m i n a t i o n disclosed an u n i n f l a m e d eye w i t h
Vol. 113, No. 5
Concomitant endophthalmitis, vaginitis, and onychomycosis caused by Candida organisms in our patient might suggest some defect in cellmediated immunity that would facilitate dis seminated infection with Candida organisms. However, normal results of skin and lympho cyte function testing against Candida antigen, normal results of T-lymphocyte immunodefi ciency testing, and repeated negative serologic testing for HIV mitigate against immunosuppression. Endogenous endophthalmitis caused by Can dida organisms may develop in a healthy, immunocompetent patient who lacks the typical risk factors for this opportunistic infection, par ticularly if localized, extraocular infection with Candida organisms coexists.
References 1. Holland, G. N.: Endogenous fungal infections of the retina and choroid. In Ryan, S. J. (ed.): Retina, vol. 2. St. Louis, C. V. Mosby, 1989, p. 625. 2. McLean, J. M.: Oculomycosis. Am. J. Ophthalmol. 56:537, 1963. 3. Edwards, J. E., Foos, R. Y., Montgomerie, J. Z., and Guze, L. B.: Ocular manifestations of Candida septicemia. Review of seventy-six cases of hematogenous Candida endophthalmitis. Medicine 53:47, 1974. 4. Schmid, S., Martenet, A. C., and Oelz, O.: Can dida endophthalmitis. Clinical presentation, treat ment and outcome in 23 patients. Infection 19:21, 1991. 5. Daily, M. J., Dickey, J. B., and Packo, K. H.: Endogenous Candida endophthalmitis after intrave nous anesthesia with propofol. Arch. Ophthalmol. 109:1081, 1991.
Pneumocystis carinii of the Orbit Dorothy N. Friedberg, M.D., Floyd A. Warren, M.D., M o o n H. Lee, M.D., Christina Vallejo, M.D., and R. Christine M e l t o n , M.D. Department of Ophthalmology, New York University Medical Center (D.N.F., F.A.W.); and Departments of Pathology (M.H.L., C.V.) and Ophthalmology (F.A.W., R.C.M.), St. Vincent's Hospital.
595
Inquiries to Dorothy N. Friedberg, M.D., Department of Ophthalmology, New York University Medical Center, 550 First Ave., New York, NY 10016. The increased use of aerosolized pentamidine prophylaxis is believed to be instrumental in the rise of disseminated extrapulmonary Pneumocystis carinii infection. 1,2 Pneumocystis choroidopathy is a recently described example of ocular opportunistic infection in the ac quired immunodeficiency syndrome. 3 4 We en countered another ophthalmic manifestation of pneumocystis infection. The patient was a 32-year-old man in whom AIDS was diagnosed in April 1988 after an episode of P. carinii pneumonia. He was initial ly treated with trimethoprim and sulfamethoxazole. In September 1988 aerosolized pentamidine therapy was started. The patient's ophthalmic history was unremarkable until September 1989 when he was examined be cause of blurred vision and pain on movement in the right eye. Examination of the anterior segment including pupillary reaction was re ported to be normal. Ophthalmoscopy dis closed retinal edema, and a diagnosis of central serous retinopathy was considered. The patient returned two months later with increased blurred vision and pain on eye move ment in the right eye. Visual acuity in the right eye was 20/25, and there was mild edema of the right optic nerve inferiorly. Magnetic reso nance imaging of the head and orbit was nor mal. Over the next three weeks the patient's visual acuity in the right eye deteriorated to 20/200; color vision diminished; optic nerve edema increased; and an afferent pupillary de fect developed. Results of examination of the left eye continued to be normal. The patient was first seen for neuro-ophthalmic consultation in December 1989. Visual acu ity was R.E.: counting fingers at 6 feet, and L.E.: 20/15. All color plates were missed with the right eye, and the visual field was markedly constricted. An afferent pupillary defect was present. There was no proptosis or tenderness of the globe on retropulsion; motility was nor mal. There was mild swelling of the optic nerve and a diffuse loss of the nerve fiber layer. The left eye was normal. Magnetic resonance imag ing was normal, and a spinal tap with cytology was recommended. The patient refused and was lost to follow-up until April 1990. At that time visual acuity in the right eye was no light perception. There was 4 mm of proptosis and a
596
May, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
d e n c e of d i s s e m i n a t e d p n e u m o c y s t i s infection. The p a t i e n t d i e d in June 1 9 9 1 . N o a u t o p s y was obtained.
References
Fig. 1 (Friedberg and associates). Computed tomographic scan demonstrates diffuse right orbital mass.
m a s s on c o m p u t e d t o m o g r a p h i c scan; n e e d l e aspiration was nondiagnostic. The p a t i e n t refused further e x a m i n a t i o n u n t i l O c t o b e r 1990 w h e n h e was s e e n b e c a u s e of 9 m m of p r o p t o s i s a n d a n i n t r a c o n a l m a s s on c o m p u t e d t o m o g r a p h i c scan (Fig. 1). N e e d l e b i o p s y was a g a i n n o n d i a g n o s t i c , a n d a n o p e n biopsy was p e r f o r m e d . This s h o w e d g r a n u l o m a t o u s i n f l a m m a t i o n m i x e d w i t h foamy m a t e r i a l c o n t a i n i n g P. carinii o r g a n i s m s , d e m o n s t r a t e d w i t h silver m e t h e n a m i n e a n d G i e m s a s t a i n s (Fig. 2). The p a t i e n t w a s t r e a t e d w i t h t r i m e t h o p r i m a n d s u l f a m e t h o x a z o l e . The p r o p t o s i s r e s p o n d e d d r a m a t i c a l l y . T h e r e was n o o t h e r evi-
Fig. 2 (Friedberg and associates). Histologic section of the lesion shows granulomatous inflammation mixed with foamy amorphous material (hematoxylin and eosin, x 100). Upper inset, Cysts of P. carinii with wall thickening (Gomori's methenamine silver, x 1,000). Lower inset, Cyst of P. carinii with intracystic bodies (Giemsa, x 1,000).
1. Armstrong, D.: Aerosol pentamidine. Ann. In tern. Med. 109:852, 1988. 2. Raviglione, M. C , Mariuz, P., Sugar, J., and Mullen, M.: Extrapulmonary pneumocystis infection. Ann. Intern. Med. 111:339, 1989. 3. Rao, N. A., Zimmerman, P. L., Boyer, D., Bis was, J., Causey, D., Beniz, J., and Nichols, P. W.: A clinical, histopathologic, and electron microscopic study of Pneumocystis carinii choroiditis. Am. J. Ophthalmol. 107:218, 1989. 4. Shami, M. J., Freeman, W., Friedberg, D., Siderides, E., Listhaus, A., and Ai, E.: A multicenter study of Pneumocystis choroidopathy. Am. J. Ophthalmol. 112:15, 1991.
Propionibacterium acnes Keratitis Gerald W. Zaidman, M.D. Department of Ophthalmology, Westchester County Medical Center, New York Medical College. Pre sented at the Ocular Microbiology and Immunology Group Meeting, Anaheim, California, Oct. 12, 1991. Inquiries to Gerald W. Zaidman, M.D., Department of Ophthalmology, Westchester County Medical Center, Valhalla, NY 10595. Propionibacterium acnes is a u b i q u i t o u s or g a n i s m of low v i r u l e n c e c o m m o n l y f o u n d in s e b a c e o u s g l a n d s . 1 It is an o p p o r t u n i s t i c p a t h o gen that h a s b e e n associated w i t h infections of p r o s t h e t i c devices such as artificial h i p s , h e a r t valves, a n d i n t r a o c u l a r lenses. 2 In the eye, P. acnes h a s c a u s e d conjunctivitis, orbital a n d p r e s e p t a l cellulitis, a n d d e l a y e d e n d o p h t h a l m i tis. 1 I t r e a t e d a p a t i e n t w h o h a d P. acnes kerati tis. A 3 3 - y e a r - o l d w o m a n was referred in N o v e m b e r 1990. The p a t i e n t h a d a t w o - m o n t h history of i n t e r m i t t e n t p h o t o p h o b i a a n d for eign b o d y s e n s a t i o n in her r i g h t eye. She d e n i e d any allergies, t r a u m a , or c o n t a c t - l e n s w e a r . The p a t i e n t h a d b e e n t r e a t e d topically w i t h v a r i o u s a n t i b i o t i c s , c o r t i c o s t e r o i d s , a n d artificial tears. E x a m i n a t i o n disclosed an u n i n f l a m e d eye w i t h