Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis

This paper was presented in part at the Annual Meeting of the American Ophthalmologic Society, Pebble Beach, May 21–24, 2000.
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Abstract

PURPOSE: To describe clinical and/or histopathologic features that could help distinguish endogenous Candida endophthalmitis from endogenous Aspergillus intraocular inflammation and to provide histologic documentation of intraocular spread of these agents.

METHODS: Twenty-five patients who underwent enucleation, 13 with morphologic features and/or positive culture for Aspergillus and 12 with histologic evidence and/or positive culture for Candida were included in the study. Clinical information was sought from each case. Patients with AIDS were excluded. The enucleated globes were analyzed to detect location of the fungi, vascular invasion by these agents, and inflammatory response.

RESULTS: Candida endophthalmitis was noted in patients with a history of gastrointestinal surgery, hyperalimentation, or diabetes mellitus, whereas aspergillosis was present in patients who had undergone organ transplantation or cardiac surgery. Histopathologically, the vitreous was the primary focus of infection for Candida, whereas subretinal/subretinal pigment epithelium infection was noted in eyes with aspergillosis. Retinal and choroidal vessel wall invasion by fungal elements was noted in cases of aspergillosis but not in cases with candidiasis. Both infectious agents induced suppurative nongranulomatous inflammation.

CONCLUSIONS: Unlike Candida endophthalmitis, aspergillosis clinically presents with extensive areas of deep retinitis/choroiditis, and vitreous biopsy may not yield positive results. Histopathologically, it appears that Aspergillus grows preferentially along subretinal pigment epithelium and subretinal space. This intraocular infection is usually associated with a high rate of mortality caused by cerebral and cardiac complications.

Section snippets

Materials and methods

In this retrospective study, files of 25 patients with a diagnosis of endogenous Candida or Aspergillus endophthalmitis were reviewed. Files were obtained from the Armed Forces Institute of Pathology and the Ophthalmic Pathology Laboratory of the Doheny Eye Institute. Only cases with the globes removed at surgery or autopsy were included. The globes were examined macroscopically and sectioned primarily through the pathologic changes. The section included cornea, anterior chamber, the chamber

Results

Demographic features and underlying systemic diseases of the 25 cases are summarized in TABLE 1, TABLE 2. Patients initially presented with diagnoses of granulomatous anterior uveitis, vitritis, vitreoretinitis, panuveitis, chorioretinitis, or endophthalmitis (Table 3). Only one case of Aspergillus endophthalmitis presented with clinical features of a granulomatous anterior uveitis. Vitritis or vitreoretinitis was diagnosed in seven patients with Candida infection and two patients with

Discussion

The present clinicopathologic study of endogenous mycotic endophthalmitis reveals differences in the clinical presentations and histopathologic features of Candida endophthalmitis and aspergillosis. These include systemic predisposing conditions, extent of subretinal and choroidal involvement by the fungi, invasion of retinal and choroidal vessels by the organisms, and mortality from central nervous system involvement. As in previous reports, a history of gastrointestinal surgery and

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    This work was supported in part by Grant EY03040, National Institutes of Health, Bethesda, Maryland, and Research to Prevent Blindness, New York, New York.

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